Healthcare Provider Details

I. General information

NPI: 1386234847
Provider Name (Legal Business Name): MR. RENE SANDOVAL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2021
Last Update Date: 01/19/2021
Certification Date: 01/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

760 MOUNTAIN VIEW ST
ALTADENA CA
91001-4996
US

IV. Provider business mailing address

867 N FAIR OAKS AVE
PASADENA CA
91103-3050
US

V. Phone/Fax

Practice location:
  • Phone: 626-798-6793
  • Fax:
Mailing address:
  • Phone: 747-283-9570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number225400000X
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: