Basic Information
| Provider Information | |||||||||
| NPI: | 1609126218 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHACON | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1359 N GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917241016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264302900 | ||||||||
| FaxNumber: | 6263310035 | ||||||||
| Practice Location | |||||||||
| Address1: | 1359 N GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917241016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264302900 | ||||||||
| FaxNumber: | 6263310035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2012 | ||||||||
| LastUpdateDate: | 03/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 225400000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 95-3893470 | 01 | CA | MEDI-CAL | OTHER |