Basic Information
Provider Information | |||||||||
NPI: | 1497880744 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MARTINEZ | ||||||||
FirstName: | RUDOLPH | ||||||||
MiddleName: | ALBERT | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | BSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MARTINEZ | ||||||||
OtherFirstName: | RUDY | ||||||||
OtherMiddleName: | ALBERT | ||||||||
OtherNamePrefix: | MR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | BSW | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 15107 WALBROOK DR | ||||||||
Address2: |   | ||||||||
City: | HACIENDA HEIGHTS | ||||||||
State: | CA | ||||||||
PostalCode: | 917451431 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6263303008 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1126 N GRAND AVE | ||||||||
Address2: |   | ||||||||
City: | COVINA | ||||||||
State: | CA | ||||||||
PostalCode: | 917241551 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6269671667 | ||||||||
FaxNumber: | 6269676027 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/23/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X |   |   | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |   |
No ID Information.