MEDICARE: NICHOLE SANDOVAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QH0100X	Health Service Clinic/Center

General Provider Information

NPI Number	:	1619477866
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLE SANDOVAL

Provider Business Mailing Address
First Line	:	1427 PINGREE AVE
Second Line	:
City	:	LINCOLN PARK
State	:	MI
Zip	:	48146-2094
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1427 PINGREE AVE
Second Line	:
City	:	LINCOLN PARK
State	:	MI
Zip	:	48146-2094
Country	:	US
Telephone Number	:	313-784-7489
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/14/2018
Last Update Date	:	02/14/2018

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Directions to “ NICHOLE SANDOVAL ” Practice Location

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