Provider Demographics
NPI:1639849979
Name:SANDOVAL, EDWARD MICHAEL (LMT)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:MICHAEL
Last Name:SANDOVAL
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2709 STONE HEDGE
Mailing Address - Street 2:
Mailing Address - City:EAGLE PASS
Mailing Address - State:TX
Mailing Address - Zip Code:78852-3239
Mailing Address - Country:US
Mailing Address - Phone:830-319-8816
Mailing Address - Fax:
Practice Address - Street 1:1835 S. VETERANS BLVD
Practice Address - Street 2:SUITE 4
Practice Address - City:EAGLE PASS
Practice Address - State:TX
Practice Address - Zip Code:78852
Practice Address - Country:US
Practice Address - Phone:830-319-8816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-17
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT135526225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist