Provider Demographics
NPI:1639691397
Name:SARAH APOLLO DT PC
Entity type:Organization
Organization Name:SARAH APOLLO DT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:L
Authorized Official - Last Name:SANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:661-993-8941
Mailing Address - Street 1:PO BOX 36
Mailing Address - Street 2:
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629-0036
Mailing Address - Country:US
Mailing Address - Phone:714-202-7909
Mailing Address - Fax:866-242-5109
Practice Address - Street 1:22 ODYSSEY STE 155
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3194
Practice Address - Country:US
Practice Address - Phone:714-202-7909
Practice Address - Fax:866-242-5109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-13
Last Update Date:2017-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6613261QR0400X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitationGroup - Single Specialty