1720245798 NPI number — MR. GENARO SANDOVAL JR. B.A., LCDC

Table of content: MR. GENARO SANDOVAL JR. B.A., LCDC (NPI 1720245798)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720245798 NPI number — MR. GENARO SANDOVAL JR. B.A., LCDC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SANDOVAL
Provider First Name:
GENARO
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
B.A., LCDC
Provider Gender Code:
M

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:
1720245798
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/05/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 E STASSNEY LN APT 437
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78745-3253
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-659-3518
Provider Business Mailing Address Fax Number:
512-252-8764

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7703 N LAMAR BLVD STE 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78752-1003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-659-3518
Provider Business Practice Location Address Fax Number:
512-252-8764
Provider Enumeration Date:
05/19/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  10685 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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