Healthcare Provider Details

I. General information

NPI: 1265379994
Provider Name (Legal Business Name): WEASPORA SPC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2026
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8623 S VERMONT AVE APT 6
LOS ANGELES CA
90044-4855
US

IV. Provider business mailing address

8623 S VERMONT AVE APT 6
LOS ANGELES CA
90044-4855
US

V. Phone/Fax

Practice location:
  • Phone: 323-781-5238
  • Fax:
Mailing address:
  • Phone: 323-781-5238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name: MR. SUTIWEYU SANDOVAL
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 323-781-5238