MEDICARE: SANDAL, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	305R00000X	Preferred Provider Organization	14444	WV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003017492
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SANDAL, INC

Provider Business Mailing Address
First Line	:	2910 EMERSON AVE
Second Line	:
City	:	PARKERSBURG
State	:	WV
Zip	:	26104-2519
Country	:	US
Telephone Number	:	304-428-1900
Fax Number	:	304-428-1976

Provider Business Practice Location Address
First Line	:	2910 EMERSON AVE
Second Line	:
City	:	PARKERSBURG
State	:	WV
Zip	:	26104-2519
Country	:	US
Telephone Number	:	304-428-1900
Fax Number	:	304-428-1976

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. ALLAN DIP FIGUEROA
Credential	:	M.D.
Telephone Number	:	304-428-1900

Provider Enumeration Date	:	05/31/2007
Last Update Date	:	11/08/2007

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Directions to “SANDAL, INC ” Practice Location

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