Healthcare Provider Details

I. General information

NPI: 1467883959
Provider Name (Legal Business Name): SANFORD SELCON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2013
Last Update Date: 12/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8420 QUAIL OAKS DR
GRANITE BAY CA
95746-6066
US

IV. Provider business mailing address

8420 QUAIL OAKS DR
GRANITE BAY CA
95746-6066
US

V. Phone/Fax

Practice location:
  • Phone: 916-791-2895
  • Fax:
Mailing address:
  • Phone: 916-791-2895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberC29359
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: