Healthcare Provider Details

I. General information

NPI: 1790156222
Provider Name (Legal Business Name): SANDRA LEE LANGSTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2015
Last Update Date: 10/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1206 CLINTON RD
JACKSON MI
49202-2005
US

IV. Provider business mailing address

1206 CLINTON RD
JACKSON MI
49202-2005
US

V. Phone/Fax

Practice location:
  • Phone: 517-783-4250
  • Fax: 517-783-4164
Mailing address:
  • Phone: 517-783-4250
  • Fax: 517-783-4164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6401005369
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: