Healthcare Provider Details

I. General information

NPI: 1023672391
Provider Name (Legal Business Name): ESMERALDA GARZA SANDOVAL JR.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2019
Last Update Date: 04/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 E MORRIS AVE
MODESTO CA
95354-0437
US

IV. Provider business mailing address

421 E MORRIS AVE
MODESTO CA
95354-0437
US

V. Phone/Fax

Practice location:
  • Phone: 209-558-7494
  • Fax: 209-558-8918
Mailing address:
  • Phone: 209-558-7494
  • Fax: 209-558-8918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code405300000X
TaxonomyPrevention Professional
License NumberN5840848
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: