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General NPI Number Information
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NPI Number | 1922408756
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Entity Type | Individual
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Provider Name | MR. SANJAYA SATRIYA UTAMA
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Gender | Male
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Dates
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Enumeration Date | 08/29/2014
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Last Update Date | 11/05/2018
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Provider Practice Location Address
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Address Line | 190 SIERRA CT UNIT B # A -115
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City | PALMDALE
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State | CA
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Zip | 93550
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Country | US
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Telephone | 661-886-0287
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Fax |
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Provider Business Mailing Address
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Address Line | 190 SIERRA CT # B # A - 115
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City | PALMDALE
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State | CA
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Zip | 93550-7607
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Country | US
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Telephone | 661-886-0287
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 172A00000X
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Taxonomy Name | Driver
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License Number |
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License Number State |
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