Provider Demographics
NPI:1912142944
Name:SANDEN, MICHAEL (DPT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:SANDEN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 10TH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:LOS OSOS
Mailing Address - State:CA
Mailing Address - Zip Code:93402-3244
Mailing Address - Country:US
Mailing Address - Phone:805-528-3002
Mailing Address - Fax:805-528-5341
Practice Address - Street 1:2115 10TH ST
Practice Address - Street 2:
Practice Address - City:LOS OSOS
Practice Address - State:CA
Practice Address - Zip Code:93402-3244
Practice Address - Country:US
Practice Address - Phone:805-528-3002
Practice Address - Fax:805-528-5341
Is Sole Proprietor?:No
Enumeration Date:2008-12-04
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT35017225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT35017OtherSTATE LICENSE
CACX234ZMedicare PIN
CAPT35017OtherSTATE LICENSE