Provider Demographics
NPI:1285032276
Name:SANDOVAL, TIFFANY (CMT)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32234 PASEO ADELANTO STE C
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-3622
Mailing Address - Country:US
Mailing Address - Phone:949-838-4436
Mailing Address - Fax:800-269-6304
Practice Address - Street 1:30220 RANCHO VIEJO RD
Practice Address - Street 2:SUITE #E
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-1568
Practice Address - Country:US
Practice Address - Phone:949-838-4436
Practice Address - Fax:800-269-6304
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-08
Last Update Date:2022-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46521174400000X, 204D00000X, 225700000X, 204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialist
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist