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General NPI Number Information
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NPI Number | 1629322649
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Entity Type | Individual
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Provider Name | IVAN DE JESUS MARTINEZ I L.M.T.
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Gender | Male
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Dates
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Enumeration Date | 10/29/2012
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Last Update Date | 10/29/2012
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Provider Practice Location Address
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Address Line | 8917 NW 178TH ST
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City | HIALEAH
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State | FL
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Zip | 33018-6554
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Country | US
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Telephone | 786-348-9601
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Fax |
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Provider Business Mailing Address
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Address Line | 8917 NW 178TH ST
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City | HIALEAH
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State | FL
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Zip | 33018-6554
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Country | US
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Telephone | 786-348-9601
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | MA45836
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License Number State | FL
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