Healthcare Provider Details

I. General information

NPI: 1548817307
Provider Name (Legal Business Name): SANDY DIMANCHE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2019
Last Update Date: 10/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11326 202ND ST
SAINT ALBANS NY
11412-2531
US

IV. Provider business mailing address

11326 202ND ST
SAINT ALBANS NY
11412-2531
US

V. Phone/Fax

Practice location:
  • Phone: 201-397-0496
  • Fax:
Mailing address:
  • Phone: 201-397-0496
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0208X
TaxonomyMobile Radiology Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code335V00000X
TaxonomyPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
License Number
License Number State

VIII. Authorized Official

Name: SANDY DIMANCHE
Title or Position: CEO
Credential: RDMS. RDCS, RVT
Phone: 201-397-0496