Healthcare Provider Details

I. General information

NPI: 1891346110
Provider Name (Legal Business Name): MICHAEL ROBERT SANDOVAL DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2019
Last Update Date: 09/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1619 E EDINGER AVE
SANTA ANA CA
92705-5001
US

IV. Provider business mailing address

934 S GUNTHER ST
SANTA ANA CA
92704-2311
US

V. Phone/Fax

Practice location:
  • Phone: 714-542-8904
  • Fax:
Mailing address:
  • Phone: 714-454-9198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number296945
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: