Provider Demographics
NPI:1124310982
Name:SANDOVAL, JAMES (NONE)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:SANDOVAL
Suffix:
Gender:M
Credentials:NONE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1289
Mailing Address - Street 2:
Mailing Address - City:THOREAU
Mailing Address - State:NM
Mailing Address - Zip Code:87323-1289
Mailing Address - Country:US
Mailing Address - Phone:505-905-0061
Mailing Address - Fax:505-905-0064
Practice Address - Street 1:.5 MILES EAST OF HWY 371
Practice Address - Street 2:
Practice Address - City:THOREAU
Practice Address - State:NM
Practice Address - Zip Code:87323
Practice Address - Country:US
Practice Address - Phone:505-905-0061
Practice Address - Fax:505-905-0064
Is Sole Proprietor?:No
Enumeration Date:2011-05-11
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM101Y00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM8600922335OtherNAVAJO NATION