MEDICARE: NATHAN PETER SANDOVAL DPT

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	225100000X	Physical Therapist	PTL.0012944	CO

General Provider Information

NPI Number	:	1861842072
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NATHAN PETER SANDOVAL DPT

Provider Business Mailing Address
First Line	:	AVENIDA REPUBLICA E6-505 Y ELOY ALFARO
Second Line	:	TORRE AQUA, DEPT. 1004
City	:	QUITO
State	:	PICHINCHA
Zip	:	170150
Country	:	EC
Telephone Number	:	99-936-9074
Fax Number	:

Provider Business Practice Location Address
First Line	:	AVENIDA REPUBLICA E6-505 Y ELOY ALFARO
Second Line	:	TORRE AQUA, DEPT. 1004
City	:	QUITO
State	:	PICHINCHA
Zip	:	170150
Country	:	EC
Telephone Number	:	99-936-9074
Fax Number	:

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

Provider Enumeration Date	:	06/18/2016
Last Update Date	:	06/18/2016

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