Provider Demographics
NPI:1306025036
Name:SANDOVAL CENTER FOR MEDICINE, CHARTERED
Entity Type:Organization
Organization Name:SANDOVAL CENTER FOR MEDICINE, CHARTERED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDOVAL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-333-1472
Mailing Address - Street 1:PO BOX 7130
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83707-1130
Mailing Address - Country:US
Mailing Address - Phone:208-333-1472
Mailing Address - Fax:208-333-7757
Practice Address - Street 1:1199 SHORELINE LN
Practice Address - Street 2:STE. 310
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6813
Practice Address - Country:US
Practice Address - Phone:208-333-1472
Practice Address - Fax:208-333-7757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-30
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-124202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1376779Medicare PIN