Provider Demographics
NPI:1356013635
Name:SANDOVAL, MATTHEW STEVEN (RN)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:STEVEN
Last Name:SANDOVAL
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 N MADERA AVE
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-3633
Mailing Address - Country:US
Mailing Address - Phone:626-399-3874
Mailing Address - Fax:
Practice Address - Street 1:1161 E COVINA BLVD
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91724-1523
Practice Address - Country:US
Practice Address - Phone:626-966-1632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-04
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95200065163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse