Healthcare Provider Details

I. General information

NPI: 1336444678
Provider Name (Legal Business Name): JOSEPHINE IDA SANDOVAL B.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2011
Last Update Date: 01/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3611 S HARBOR BLVD SUITE 100
SANTA ANA CA
92704-6928
US

IV. Provider business mailing address

3611 S HARBOR BLVD SUITE 100
SANTA ANA CA
92704-6928
US

V. Phone/Fax

Practice location:
  • Phone: 626-709-7449
  • Fax:
Mailing address:
  • Phone: 626-709-7449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: