Provider Demographics
NPI:1114223492
Name:SANDOVAL-RUBIO, MYRIAN
Entity Type:Individual
Prefix:
First Name:MYRIAN
Middle Name:
Last Name:SANDOVAL-RUBIO
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 1:12510 VAN NUYS BLVD
Mailing Address - Street 2:209
Mailing Address - City:PACOIMA
Mailing Address - State:CA
Mailing Address - Zip Code:91331-1338
Mailing Address - Country:US
Mailing Address - Phone:818-896-2255
Mailing Address - Fax:818-897-1766
Practice Address - Street 1:12510 VAN NUYS BLVD
Practice Address - Street 2:209
Practice Address - City:PACOIMA
Practice Address - State:CA
Practice Address - Zip Code:91331-1338
Practice Address - Country:US
Practice Address - Phone:818-896-2255
Practice Address - Fax:818-897-1766
Is Sole Proprietor?:No
Enumeration Date:2011-02-02
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No101Y00000XBehavioral Health & Social Service ProvidersCounselor