Provider Demographics
NPI:1386776367
Name:SANFORD, MARTIN LUKE (DC)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:LUKE
Last Name:SANFORD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 COMMERCIAL ST
Mailing Address - Street 2:
Mailing Address - City:PORTOLA
Mailing Address - State:CA
Mailing Address - Zip Code:96122-9617
Mailing Address - Country:US
Mailing Address - Phone:530-832-4442
Mailing Address - Fax:
Practice Address - Street 1:15 COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:PORTOLA
Practice Address - State:CA
Practice Address - Zip Code:96122-9617
Practice Address - Country:US
Practice Address - Phone:530-832-4442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVB01037111N00000X
CA31697111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV05750Medicare UPIN