Basic Information
| Provider Information | |||||||||
| NPI: | 1467095513 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTINEZ | ||||||||
| FirstName: | SOPHIA | ||||||||
| MiddleName: | MARIA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MS, RDN, LD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JIMENEZ | ||||||||
| OtherFirstName: | SOPHIA | ||||||||
| OtherMiddleName: | MARIA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MS, RDN, LD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2829 23RD ST | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794101627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5754998460 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6104 AVENUE Q | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794123506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8064723400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2019 | ||||||||
| LastUpdateDate: | 10/22/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | LD-1205 | NM | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 133V00000X | DT85223 | TX | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.