Basic Information
| Provider Information | |||||||||
| NPI: | 1124669197 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANDOVAL | ||||||||
| FirstName: | ALBERT | ||||||||
| MiddleName: | JEREMY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SANDOVAL | ||||||||
| OtherFirstName: | A.J. | ||||||||
| OtherMiddleName: | JEREMY | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 2000 | ||||||||
| Address2: | |||||||||
| City: | SILVER CITY | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880622000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1000 N HUDSON ST | ||||||||
| Address2: | |||||||||
| City: | SILVER CITY | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880615516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755970211 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2019 | ||||||||
| LastUpdateDate: | 10/01/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174H00000X | 20778 | Y | Other Service Providers | Health Educator |
No ID Information.