1316136443 NPI number — L VICTOR SANDOVAL, P.C.

Table of content: (NPI 1316136443)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316136443 NPI number — L VICTOR SANDOVAL, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
L VICTOR SANDOVAL, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316136443
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
700 S TELSHOR BLVD
Provider Second Line Business Mailing Address:
STE #1534
Provider Business Mailing Address City Name:
LAS CRUCES
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88011
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-522-8334
Provider Business Mailing Address Fax Number:
575-522-1065

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 S TELSHOR BLVD
Provider Second Line Business Practice Location Address:
STE #1534
Provider Business Practice Location Address City Name:
LAS CRUCES
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88011-8608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-522-8334
Provider Business Practice Location Address Fax Number:
575-522-1065
Provider Enumeration Date:
10/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SANDOVAL
Authorized Official First Name:
L VICTOR
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
575-522-8334

Provider Taxonomy Codes

  • Taxonomy code: 152WC0802X , with the licence number:  2260 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 99429268 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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