Healthcare Provider Details

I. General information

NPI: 1790666204
Provider Name (Legal Business Name): MR. QADIR ABDUL RAHMAN SANDERS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2025
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 DOWD CIR STE A
PINEHURST NC
28374-7932
US

IV. Provider business mailing address

1808 SHADY KNOLL LN
FAYETTEVILLE NC
28314-6285
US

V. Phone/Fax

Practice location:
  • Phone: 910-295-2609
  • Fax:
Mailing address:
  • Phone: 910-535-5774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: