Provider Demographics
NPI:1154954691
Name:SANDOVAL, STEPHANIE MARLENE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MARLENE
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2219
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92244-2219
Mailing Address - Country:US
Mailing Address - Phone:760-337-7304
Mailing Address - Fax:760-352-2512
Practice Address - Street 1:510 W MAIN ST STE 104
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-2900
Practice Address - Country:US
Practice Address - Phone:760-353-7304
Practice Address - Fax:760-352-2512
Is Sole Proprietor?:No
Enumeration Date:2020-02-12
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator