Healthcare Provider Details

I. General information

NPI: 1235916008
Provider Name (Legal Business Name): JONATHAN SANDOVAL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2023
Last Update Date: 09/13/2023
Certification Date: 09/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 E FOOTHILL BLVD
PASADENA CA
91107-3406
US

IV. Provider business mailing address

1441 N LOS ROBLES AVE APT 1
PASADENA CA
91104-5531
US

V. Phone/Fax

Practice location:
  • Phone: 626-744-5242
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: