Healthcare Provider Details

I. General information

NPI: 1720587058
Provider Name (Legal Business Name): MANUEL A. MARTINEZ III LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2018
Last Update Date: 03/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3082 32ND STREET BYP
SILVER CITY NM
88061
US

IV. Provider business mailing address

700 N BULLARD ST
SILVER CITY NM
88061-5413
US

V. Phone/Fax

Practice location:
  • Phone: 575-538-2061
  • Fax: 575-538-5742
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM-10105
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: