1033110366 NPI number — DR. NICOLAS C MARTINEZ D.C, F.A.C.O

Table of content: DR. NICOLAS C MARTINEZ D.C, F.A.C.O (NPI 1033110366)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033110366 NPI number — DR. NICOLAS C MARTINEZ D.C, F.A.C.O

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTINEZ
Provider First Name:
NICOLAS
Provider Middle Name:
C
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C, F.A.C.O
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033110366
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/23/2006
NPI Reactivation Date:
04/04/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
651 W ARMITAGE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELMHURST
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60126-2122
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-833-4725
Provider Business Mailing Address Fax Number:
630-833-6756

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3720 W 26TH ST
Provider Second Line Business Practice Location Address:
2ND FL.
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60623-3824
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-277-2225
Provider Business Practice Location Address Fax Number:
773-277-1134
Provider Enumeration Date:
08/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111NX0800X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 162248 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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