1619469293 NPI number — SANDRA NIETO, MD, A MEDICAL CORPORATION

Table of content: (NPI 1619469293)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619469293 NPI number — SANDRA NIETO, MD, A MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SANDRA NIETO, MD, A MEDICAL CORPORATION
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:
1619469293
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/31/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2559
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTEBELLO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90640-7359
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-786-8833
Provider Business Mailing Address Fax Number:
323-967-6067

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
433 N 4TH ST STE 211
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTEBELLO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90640-4309
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-786-8833
Provider Business Practice Location Address Fax Number:
323-967-6067
Provider Enumeration Date:
05/31/2018

Additional Information

Authorized Official

Authorized Official Last Name:
NIETO
Authorized Official First Name:
SANDRA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
323-786-8833

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1003830258 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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