Basic Information
Provider Information | |||||||||
NPI: | 1780154542 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DE VERA | ||||||||
FirstName: | SARAH | ||||||||
MiddleName: | MASAKO | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GIFFORD | ||||||||
OtherFirstName: | SARAH | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2552 GREGORY DR # A | ||||||||
Address2: |   | ||||||||
City: | CARLSBAD | ||||||||
State: | CA | ||||||||
PostalCode: | 920081514 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8502186846 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2575 YORBA LINDA BLVD | ||||||||
Address2: |   | ||||||||
City: | FULLERTON | ||||||||
State: | CA | ||||||||
PostalCode: | 928311615 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7144497400 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/04/2018 | ||||||||
LastUpdateDate: | 11/02/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/02/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | AL5358 | FL | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 390200000X |   |   | Y |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   |
No ID Information.