Healthcare Provider Details

I. General information

NPI: 1841300423
Provider Name (Legal Business Name): MAYRA MARTINEZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 08/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARRETERA 849 BO. SANTO DOMINGO
TRUJILLO ALTO PR
00976
US

IV. Provider business mailing address

CALLE 5 BLOQUE G-9 ALTURAS DE VILLA FONTANA
CAROLINA PR
00983
US

V. Phone/Fax

Practice location:
  • Phone: 787-420-3778
  • Fax:
Mailing address:
  • Phone: 787-420-3778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License NumberTC-AMB-266
License Number StatePR

VIII. Authorized Official

Name: MR. JOSE A GAUTIER
Title or Position: ADMINISTRATOR
Credential: EMT-P
Phone: 17874203778