Healthcare Provider Details

I. General information

NPI: 1073264644
Provider Name (Legal Business Name): SANDRA CISNEROS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2022
Last Update Date: 04/15/2025
Certification Date: 04/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1295 CORONA POINTE CT STE 102
CORONA CA
92879-1721
US

IV. Provider business mailing address

PO BOX 33568
SAN DIEGO CA
92163-3568
US

V. Phone/Fax

Practice location:
  • Phone: 855-223-7123
  • Fax:
Mailing address:
  • Phone: 855-223-7123
  • Fax: 619-374-7134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: