Provider Demographics
NPI:1639514219
Name:SUBOTICH, SANDRA (LAC, DIPL OM)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:SUBOTICH
Suffix:
Gender:F
Credentials:LAC, DIPL OM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1145 HIDDEN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:SOQUEL
Mailing Address - State:CA
Mailing Address - Zip Code:95073-9708
Mailing Address - Country:US
Mailing Address - Phone:847-858-4491
Mailing Address - Fax:
Practice Address - Street 1:4170 GROSS ROAD EXT STE 6
Practice Address - Street 2:
Practice Address - City:CAPITOLA
Practice Address - State:CA
Practice Address - Zip Code:95010-2054
Practice Address - Country:US
Practice Address - Phone:831-464-1605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-08
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 15338171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist