Healthcare Provider Details

I. General information

NPI: 1477026292
Provider Name (Legal Business Name): CARLOS SANDOVAL DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2019
Last Update Date: 01/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2860 CERRILLOS RD STE C2
SANTA FE NM
87507-2326
US

IV. Provider business mailing address

1117 HARRISON RD
SANTA FE NM
87507-3290
US

V. Phone/Fax

Practice location:
  • Phone: 505-772-0114
  • Fax:
Mailing address:
  • Phone: 505-603-4467
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC2195
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: