Healthcare Provider Details

I. General information

NPI: 1932727724
Provider Name (Legal Business Name): JOSE LUIS SANDOVAL DE LEON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2020
Last Update Date: 07/08/2020
Certification Date: 07/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 S 1850 E RM 208
SALT LAKE CITY UT
84112-0910
US

IV. Provider business mailing address

260 S 1850 E RM 208
SALT LAKE CITY UT
84112-0910
US

V. Phone/Fax

Practice location:
  • Phone: 801-585-1820
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: