=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326973678
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SANFORD WEST LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2026
-----------------------------------------------------
Last Update Date | 06/17/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 221 JOHN ST NE
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49503-3237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-776-9651
-----------------------------------------------------
Fax | 616-341-6017
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15146 16TH AVE
-----------------------------------------------------
City | MARNE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49435-9605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-776-9651
-----------------------------------------------------
Fax | 616-341-6017
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE VICE PRESIDENT
-----------------------------------------------------
Name | ALEC WILLIAM GEORGE GREEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 616-446-6413
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 323P00000X
-----------------------------------------------------
Taxonomy Name | Psychiatric Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------