Basic Information
Provider Information
NPI: 1639724313
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SANDOVAL
FirstName: ALYNNA
MiddleName: LEN
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 416 GLENMOOR CIR
Address2:  
City: MILPITAS
State: CA
PostalCode: 950352947
CountryCode: US
TelephoneNumber: 4085061964
FaxNumber:  
Practice Location
Address1: 1171 HOMESTEAD RD STE 250
Address2:  
City: SANTA CLARA
State: CA
PostalCode: 950505485
CountryCode: US
TelephoneNumber: 4083202590
FaxNumber:  
Other Information
ProviderEnumerationDate: 08/08/2019
LastUpdateDate: 08/12/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
106S00000X  Y    

No ID Information.


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