Healthcare Provider Details

I. General information

NPI: 1720105992
Provider Name (Legal Business Name): SPROUT FAMILY SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 12/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3691 BEN WALTERS LN STE 4
HOMER AK
99603-7750
US

IV. Provider business mailing address

3691 BEN WALTERS LN STE 4
HOMER AK
99603-7750
US

V. Phone/Fax

Practice location:
  • Phone: 907-235-6044
  • Fax: 907-235-2644
Mailing address:
  • Phone: 907-235-6044
  • Fax: 907-235-2644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name: JILLIAN LUSH
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 907-235-6044