Basic Information
| Provider Information | |||||||||
| NPI: | 1891123493 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOLENBERG | ||||||||
| FirstName: | SANFORD | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26 E PARK DR STE 105 | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457015003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405924229 | ||||||||
| FaxNumber: | 7405924010 | ||||||||
| Practice Location | |||||||||
| Address1: | 26 E PARK DR | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457015003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405924229 | ||||||||
| FaxNumber: | 7405924010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2013 | ||||||||
| LastUpdateDate: | 04/18/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 855 | OH | Y | Chiropractic Providers | Chiropractor |
ID Information
| ID | Type | State | Issuer | Description | 0095255 | 05 | OH | MEDICAID |