Provider Demographics
NPI:1114544863
Name:SANDOVAL, JOSE ENRIQUE
Entity type:Individual
Prefix:MR
First Name:JOSE
Middle Name:ENRIQUE
Last Name:SANDOVAL
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 1:2812 E TONOPAH AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89030-7392
Mailing Address - Country:US
Mailing Address - Phone:702-788-6429
Mailing Address - Fax:
Practice Address - Street 1:4285 N RANCHO DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-3446
Practice Address - Country:US
Practice Address - Phone:800-550-2453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-29
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No174400000XOther Service ProvidersSpecialist