MEDICARE: JEANNETTE SANDOVAL LARIOS

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	164X00000X	Licensed Vocational Nurse	225490	CA

General Provider Information

NPI Number	:	1720258494
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEANNETTE SANDOVAL LARIOS

Provider Business Mailing Address
First Line	:	2310 OLIVEGATE LN
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95136-3209
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2310 OLIVEGATE LN
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95136-3209
Country	:	US
Telephone Number	:	408-510-4091
Fax Number	:

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

Provider Enumeration Date	:	03/09/2008
Last Update Date	:	03/09/2008

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