Healthcare Provider Details

I. General information

NPI: 1124886635
Provider Name (Legal Business Name): SANDRA RAE HANSBROUGH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2024
Last Update Date: 03/08/2024
Certification Date: 03/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15110 SIWINI RD # 132
FOREST RANCH CA
95942-9664
US

IV. Provider business mailing address

15110 SIWINI RD # 132
FOREST RANCH CA
95942-9664
US

V. Phone/Fax

Practice location:
  • Phone: 530-521-9300
  • Fax:
Mailing address:
  • Phone: 530-521-9300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number20395
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: