MEDICARE: RICARDO 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	405300000X	Prevention Professional	A5018449	CA

General Provider Information

NPI Number	:	1811593577
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICARDO SANDOVAL

Provider Business Mailing Address
First Line	:	5715 S BROADWAY
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90037-4131
Country	:	US
Telephone Number	:	323-948-0444
Fax Number	:

Provider Business Practice Location Address
First Line	:	5917 CONVERSE AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90001-1409
Country	:	US
Telephone Number	:	323-423-9030
Fax Number	:

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

Provider Enumeration Date	:	12/08/2020
Last Update Date	:	12/08/2020

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Directions to “ RICARDO SANDOVAL ” Practice Location

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