Healthcare Provider Details

I. General information

NPI: 1760240550
Provider Name (Legal Business Name): ADRIAN RAY SANDOVAL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2024
Last Update Date: 03/07/2024
Certification Date: 03/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1013 W UNIVERSITY AVE STE 122
GEORGETOWN TX
78628-5343
US

IV. Provider business mailing address

1013 W UNIVERSITY AVE STE 122
GEORGETOWN TX
78628-5343
US

V. Phone/Fax

Practice location:
  • Phone: 512-868-1100
  • Fax:
Mailing address:
  • Phone: 512-868-1100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number81096
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: