Healthcare Provider Details

I. General information

NPI: 1780854307
Provider Name (Legal Business Name): REY MARTINEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2008
Last Update Date: 03/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5213 JAGUAR DRIVE
SANTA FE NM
87507
US

IV. Provider business mailing address

1622 7TH ST
LAS VEGAS NM
87701-4920
US

V. Phone/Fax

Practice location:
  • Phone: 505-820-0262
  • Fax:
Mailing address:
  • Phone: 505-454-8265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberM - 05343
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: