Healthcare Provider Details

I. General information

NPI: 1912094566
Provider Name (Legal Business Name): JG SANFORD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 05/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1602 N 2ND ST
CLINTON MO
64735
US

IV. Provider business mailing address

1602 N 2ND ST
CLINTON MO
64735
US

V. Phone/Fax

Practice location:
  • Phone: 660-885-2020
  • Fax: 660-885-9375
Mailing address:
  • Phone: 660-885-2020
  • Fax: 660-885-9375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License NumberLC0010929
License Number StateMO

VIII. Authorized Official

Name: DR. EARLE GLENN SANFORD
Title or Position: MANAGING PARTNER
Credential: M.D.
Phone: 660-885-8171