Basic Information
| Provider Information | |||||||||
| NPI: | 1831624329 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTINEZ | ||||||||
| FirstName: | HEAVENLY | ||||||||
| MiddleName: | |||||||||
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| Credential: | RMT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RICKS | ||||||||
| OtherFirstName: | HEAVENLY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4617 W 20TH ST STE 2A | ||||||||
| Address2: | |||||||||
| City: | GREELEY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806343207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703529022 | ||||||||
| FaxNumber: | 9703529048 | ||||||||
| Practice Location | |||||||||
| Address1: | 4617 W 20TH ST STE 2A | ||||||||
| Address2: | |||||||||
| City: | GREELEY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806343207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703529022 | ||||||||
| FaxNumber: | 9703529048 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2017 | ||||||||
| LastUpdateDate: | 04/22/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | MT.0012230 | CO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
No ID Information.