Basic Information
| Provider Information | |||||||||
| NPI: | 1659561785 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTINEZ | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | BOSCO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 946 S MONTEROSA DR | ||||||||
| Address2: | |||||||||
| City: | PUEBLO WEST | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810076120 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11800 W 49TH AVE | ||||||||
| Address2: | |||||||||
| City: | WHEAT RIDGE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800332176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034631382 | ||||||||
| FaxNumber: | 3034231609 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2007 | ||||||||
| LastUpdateDate: | 07/25/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5496 | CO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.