Provider Demographics
NPI:1831978535
Name:QUALLS, SEAN MICHAEL
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:MICHAEL
Last Name:QUALLS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8081 LANGHAM WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95829-6071
Mailing Address - Country:US
Mailing Address - Phone:916-513-2445
Mailing Address - Fax:
Practice Address - Street 1:3301 C ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-3300
Practice Address - Country:US
Practice Address - Phone:916-551-3203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-22
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC53905225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter