Healthcare Provider Details

I. General information

NPI: 1154641405
Provider Name (Legal Business Name): ALLEN R MARTINEZ BMS COORDINATOR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2010
Last Update Date: 02/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 DON FERNANDO ST
TAOS NM
87571-5953
US

IV. Provider business mailing address

314 DON FERNANDO ST
TAOS NM
87571-5953
US

V. Phone/Fax

Practice location:
  • Phone: 575-751-7037
  • Fax: 575-758-3459
Mailing address:
  • Phone: 575-751-7037
  • Fax: 575-758-3459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: