Healthcare Provider Details

I. General information

NPI: 1407317449
Provider Name (Legal Business Name): ELLENE SANDOVAL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2019
Last Update Date: 01/23/2026
Certification Date: 01/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18533 SOLEDAD CANYON RD
SANTA CLARITA CA
91351-3722
US

IV. Provider business mailing address

14314 SEQUOIA RD
CANYON COUNTRY CA
91387-6201
US

V. Phone/Fax

Practice location:
  • Phone: 661-673-8800
  • Fax:
Mailing address:
  • Phone: 661-618-9320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA178160
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: