Healthcare Provider Details

I. General information

NPI: 1205619244
Provider Name (Legal Business Name): CONSUELO RUVALCABA SANDOVAL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2023
Last Update Date: 08/15/2023
Certification Date: 08/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2014 LINCOLNWAY E
GOSHEN IN
46526-6818
US

IV. Provider business mailing address

8237 VICELA DR
SARASOTA FL
34240-1462
US

V. Phone/Fax

Practice location:
  • Phone: 800-210-0814
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: