Provider Demographics
NPI:1427196112
Name:SANDSTROM, DAVID DANIEL (LMP)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:DANIEL
Last Name:SANDSTROM
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:724 E 31ST AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99203-3105
Mailing Address - Country:US
Mailing Address - Phone:509-475-8989
Mailing Address - Fax:
Practice Address - Street 1:802 E 29TH AVE STE 1
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99203-3201
Practice Address - Country:US
Practice Address - Phone:509-475-8989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00018242174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA00018242OtherMASSAGE LICENSE