Provider Demographics
NPI:1316008931
Name:SANDVOLD, SHADRACK MARVIN (LMT)
Entity Type:Individual
Prefix:
First Name:SHADRACK
Middle Name:MARVIN
Last Name:SANDVOLD
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1954 SE 182ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-5602
Mailing Address - Country:US
Mailing Address - Phone:503-667-8988
Mailing Address - Fax:503-667-8988
Practice Address - Street 1:1954 SE 182ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-5602
Practice Address - Country:US
Practice Address - Phone:503-667-8988
Practice Address - Fax:503-667-8988
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5239174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist