Healthcare Provider Details

I. General information

NPI: 1598029001
Provider Name (Legal Business Name): BLANCA MARTINEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2012
Last Update Date: 10/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1660 SAN JOSE RD
LA MESA NM
88044-9511
US

IV. Provider business mailing address

385 CALLE DE ALEGRA STE A
LAS CRUCES NM
88005-3423
US

V. Phone/Fax

Practice location:
  • Phone: 575-642-3551
  • Fax:
Mailing address:
  • Phone: 575-526-1105
  • Fax: 575-524-4266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: