Healthcare Provider Details

I. General information

NPI: 1518310739
Provider Name (Legal Business Name): TRINA SANFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2016
Last Update Date: 07/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9490 LOS COCHES CT
RIVERSIDE CA
92508-6814
US

IV. Provider business mailing address

9490 LOS COCHES CT
RIVERSIDE CA
92508-6814
US

V. Phone/Fax

Practice location:
  • Phone: 951-966-6515
  • Fax: 760-724-0309
Mailing address:
  • Phone: 951-966-6515
  • Fax: 760-724-0309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number374601272
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: