Basic Information
| Provider Information | |||||||||
| NPI: | 1962998922 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANGESTANIAN | ||||||||
| FirstName: | SAM | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 W MISSION BLVD # 110-397 | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917661711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9097307088 | ||||||||
| FaxNumber: | 9095756181 | ||||||||
| Practice Location | |||||||||
| Address1: | 1902 ROYALTY DR STE 170 | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917673030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096209700 | ||||||||
| FaxNumber: | 9096209800 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2018 | ||||||||
| LastUpdateDate: | 07/02/2018 | ||||||||
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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 | 225X00000X | 17115 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.