Healthcare Provider Details

I. General information

NPI: 1205937638
Provider Name (Legal Business Name): STACIE L SANDO DC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 02/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1749 E BROAD ST DEGENHART CHIROPRACTIC
HAZLETON PA
18201-5650
US

IV. Provider business mailing address

1749 EAST BROAD ST DEGENHART CHIROPRACTIC
HAZLETON PA
18201
US

V. Phone/Fax

Practice location:
  • Phone: 570-454-2474
  • Fax: 570-454-0097
Mailing address:
  • Phone: 570-454-2474
  • Fax: 570-454-0097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC009159
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1011929270001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: