1386183911 NPI number — SANDY'S COUNTRY AFC

Table of content: (NPI 1386183911)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386183911 NPI number — SANDY'S COUNTRY AFC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SANDY'S COUNTRY AFC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386183911
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/15/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12955 68TH ST SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALTO
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49302-9741
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-868-0001
Provider Business Mailing Address Fax Number:
616-868-0030

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12955 68TH ST SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALTO
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49302-9741
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-868-0001
Provider Business Practice Location Address Fax Number:
616-868-0030
Provider Enumeration Date:
02/15/2017

Additional Information

Authorized Official

Authorized Official Last Name:
AMBRUS
Authorized Official First Name:
SANDRA
Authorized Official Middle Name:
JEAN
Authorized Official Title or Position:
LICENSEE/OWNER
Authorized Official Telephone Number:
616-868-0001

Provider Taxonomy Codes

  • Taxonomy code: 311ZA0620X , with the licence number:  AM410281990 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9455674 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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