Healthcare Provider Details

I. General information

NPI: 1356100531
Provider Name (Legal Business Name): SORAYA LORENA SANDOVAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2024
Last Update Date: 12/03/2024
Certification Date: 03/18/2024
Deactivation Date: 11/13/2024
Reactivation Date: 12/03/2024

III. Provider practice location address

3633 E BROADWAY
LONG BEACH CA
90803-6035
US

IV. Provider business mailing address

3633 E BROADWAY
LONG BEACH CA
90803-6035
US

V. Phone/Fax

Practice location:
  • Phone: 562-285-1330
  • Fax:
Mailing address:
  • Phone: 562-285-1330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: