Healthcare Provider Details

I. General information

NPI: 1962808303
Provider Name (Legal Business Name): JUAN CARLOS MARTINEZ-MORENO MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2014
Last Update Date: 06/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3017 W CHARLESTON BLVD SUITE 90
LAS VEGAS NV
89102-1941
US

IV. Provider business mailing address

3017 W CHARLESTON BLVD SUITE 90
LAS VEGAS NV
89102-1941
US

V. Phone/Fax

Practice location:
  • Phone: 702-826-2816
  • Fax: 702-826-2813
Mailing address:
  • Phone: 702-826-2816
  • Fax: 702-826-2813

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number StateNV

VIII. Authorized Official

Name: DR. JUAN CARLOS MARTINEZ-MORENO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 702-826-2816