1740588045 NPI number — ADRIENNE MARLISSA MARTINEZ OTR

Table of content: ADRIENNE MARLISSA MARTINEZ OTR (NPI 1740588045)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740588045 NPI number — ADRIENNE MARLISSA MARTINEZ OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTINEZ
Provider First Name:
ADRIENNE
Provider Middle Name:
MARLISSA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR
Provider Gender Code:
F

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:
1740588045
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/16/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3601 BUDDY OWENS
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
MCALLEN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78504-3003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
956-631-6200
Provider Business Mailing Address Fax Number:
956-631-1117

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3601 BUDDY OWENS
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
MCALLEN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78504-3003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-631-6200
Provider Business Practice Location Address Fax Number:
956-631-1117
Provider Enumeration Date:
03/10/2011

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: 225X00000X , with the licence number:  114053 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 114053 . This is a "LICENSE NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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