=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568234417
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANIEL FRED MARTINEZ JR. LAT, ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2023
-----------------------------------------------------
Last Update Date | 10/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7227 S SIMMS ST
-----------------------------------------------------
City | LITTLETON
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80127-3245
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-982-3670
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9800 MARMOT RIDGE CIR
-----------------------------------------------------
City | LITTLETON
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80125-8425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-427-3181
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | AT.0000680
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------