Provider Demographics
NPI:1679248496
Name:SANFORD WEST LLC
Entity type:Organization
Organization Name:SANFORD WEST LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING & CONTRACTING MANAGE
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBINSON TALBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-520-9074
Mailing Address - Street 1:15146 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:MARNE
Mailing Address - State:MI
Mailing Address - Zip Code:49435-9605
Mailing Address - Country:US
Mailing Address - Phone:616-288-6970
Mailing Address - Fax:
Practice Address - Street 1:15146 16TH AVE
Practice Address - Street 2:
Practice Address - City:MARNE
Practice Address - State:MI
Practice Address - Zip Code:49435-9605
Practice Address - Country:US
Practice Address - Phone:616-288-6970
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SANFORD WEST LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-08-13
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility