Provider Demographics
NPI:1053414052
Name:SANDRA L VITALE
Entity type:Organization
Organization Name:SANDRA L VITALE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:L
Authorized Official - Last Name:VITALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-575-1063
Mailing Address - Street 1:1005 W ORANGEBURG AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4163
Mailing Address - Country:US
Mailing Address - Phone:209-575-1063
Mailing Address - Fax:209-575-1065
Practice Address - Street 1:1005 W ORANGEBURG AVE
Practice Address - Street 2:SUITE A
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4163
Practice Address - Country:US
Practice Address - Phone:209-575-1063
Practice Address - Fax:209-575-1065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGXC000360Medicaid
CAGXC000360Medicaid