Provider Demographics
NPI:1629839451
Name:LEIVA SANCHEZ, CARLOS RAUL (SA-C)
Entity Type:Individual
Prefix:MR
First Name:CARLOS
Middle Name:RAUL
Last Name:LEIVA SANCHEZ
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3264 PLUM CREEK DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43219-7341
Mailing Address - Country:US
Mailing Address - Phone:830-596-3603
Mailing Address - Fax:
Practice Address - Street 1:3264 PLUM CREEK DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43219-7341
Practice Address - Country:US
Practice Address - Phone:830-596-3603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-18
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21-527246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant