Healthcare Provider Details

I. General information

NPI: 1114846045
Provider Name (Legal Business Name): KYLIE SANDOVAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4740 GREEN RIVER RD
CORONA CA
92878-9185
US

IV. Provider business mailing address

29106 MANGO ST
LAKE ELSINORE CA
92530-7221
US

V. Phone/Fax

Practice location:
  • Phone: 888-515-1793
  • Fax:
Mailing address:
  • Phone: 951-816-1627
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: