Healthcare Provider Details

I. General information

NPI: 1003017492
Provider Name (Legal Business Name): SANDAL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 11/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2910 EMERSON AVE
PARKERSBURG WV
26104-2519
US

IV. Provider business mailing address

2910 EMERSON AVE
PARKERSBURG WV
26104-2519
US

V. Phone/Fax

Practice location:
  • Phone: 304-428-1900
  • Fax: 304-428-1976
Mailing address:
  • Phone: 304-428-1900
  • Fax: 304-428-1976

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number14444
License Number StateWV

VIII. Authorized Official

Name: DR. ALLAN DIP FIGUEROA
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 304-428-1900