Provider Demographics
NPI:1992265458
Name:SANDOVAL, MYLES
Entity type:Individual
Prefix:
First Name:MYLES
Middle Name:
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 NARA VISA RD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-6017
Mailing Address - Country:US
Mailing Address - Phone:512-294-6479
Mailing Address - Fax:
Practice Address - Street 1:980 BOSQUE FARMS BLVD
Practice Address - Street 2:
Practice Address - City:BOSQUE FARMS
Practice Address - State:NM
Practice Address - Zip Code:87068-9652
Practice Address - Country:US
Practice Address - Phone:505-554-0052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-21
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPT6032225100000X
TX1316075225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty