Healthcare Provider Details

I. General information

NPI: 1811609159
Provider Name (Legal Business Name): MR. CARL BEN SAIN JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2022
Last Update Date: 12/19/2022
Certification Date: 12/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3808 CAMELOT DR SE APT 1B
GRAND RAPIDS MI
49546-6043
US

IV. Provider business mailing address

3808 CAMELOT DR SE APT 1B
GRAND RAPIDS MI
49546-6043
US

V. Phone/Fax

Practice location:
  • Phone: 616-500-4098
  • Fax:
Mailing address:
  • Phone: 616-500-4098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number5803200207
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: