MEDICARE: VIRNA YANETH SANDOVAL

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1053001065
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VIRNA YANETH SANDOVAL

Provider Business Mailing Address
First Line	:	1212 SAN JOSE DR
Second Line	:
City	:	ANTIOCH
State	:	CA
Zip	:	94509-4634
Country	:	US
Telephone Number	:	925-301-5833
Fax Number	:

Provider Business Practice Location Address
First Line	:	1212 SAN JOSE DR
Second Line	:
City	:	ANTIOCH
State	:	CA
Zip	:	94509-4634
Country	:	US
Telephone Number	:	925-301-5833
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/11/2023
Last Update Date	:	05/11/2023

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Directions to “ VIRNA YANETH SANDOVAL ” Practice Location

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