Healthcare Provider Details

I. General information

NPI: 1053414052
Provider Name (Legal Business Name): SANDRA L VITALE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 W ORANGEBURG AVE SUITE A
MODESTO CA
95350-4163
US

IV. Provider business mailing address

1005 W ORANGEBURG AVE SUITE A
MODESTO CA
95350-4163
US

V. Phone/Fax

Practice location:
  • Phone: 209-575-1063
  • Fax: 209-575-1065
Mailing address:
  • Phone: 209-575-1063
  • Fax: 209-575-1065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MS. SANDY L VITALE
Title or Position: OWNER
Credential:
Phone: 209-575-1063