Provider Demographics
NPI:1619516986
Name:SANDOVAL CRUZ, MARCO ANTONIO
Entity Type:Individual
Prefix:
First Name:MARCO
Middle Name:ANTONIO
Last Name:SANDOVAL CRUZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MARCO
Other - Middle Name:ANTONIO
Other - Last Name:SANDOVAL CRUZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:336 S. JONES BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89107-0000
Mailing Address - Country:US
Mailing Address - Phone:702-953-7910
Mailing Address - Fax:702-953-2250
Practice Address - Street 1:336 S. JONES BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89107-0000
Practice Address - Country:US
Practice Address - Phone:702-953-7910
Practice Address - Fax:702-953-2250
Is Sole Proprietor?:No
Enumeration Date:2020-01-03
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant