Healthcare Provider Details

I. General information

NPI: 1932462124
Provider Name (Legal Business Name): GURPREET SANDHU OTR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2012
Last Update Date: 06/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 311, 2488 KELLY AVENUE
PORT COQUITLAM ALBERTA
V3C 1Y4
CA

IV. Provider business mailing address

UNIT 311. 2488 KELLY AVENUE
PORT COQUITLAM ALBERTA
T6R3S2
CA

V. Phone/Fax

Practice location:
  • Phone: 778-378-3758
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: