Healthcare Provider Details

I. General information

NPI: 1689601924
Provider Name (Legal Business Name): LISA ELLEN SANDOVAL ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W HOBBS ST
ROSWELL NM
88203-1834
US

IV. Provider business mailing address

2803 PURDUE DR
ROSWELL NM
88203-2375
US

V. Phone/Fax

Practice location:
  • Phone: 505-637-3200
  • Fax:
Mailing address:
  • Phone: 505-625-1968
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number186
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: