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General NPI Number Information
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NPI Number | 1578378717
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Entity Type | Individual
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Provider Name | LUCAS MARK SANFORD CSFA
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Gender | Male
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Dates
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Enumeration Date | 02/12/2025
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Last Update Date | 02/12/2025
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Provider Practice Location Address
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Address Line | 100 MICHIGAN ST NE
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City | GRAND RAPIDS
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State | MI
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Zip | 49503-2560
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Country | US
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Telephone | 866-989-7999
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Fax |
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Provider Business Mailing Address
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Address Line | 3804 YORKLAND DR NW APT 9
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City | COMSTOCK PARK
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State | MI
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Zip | 49321-8892
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Country | US
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Telephone | 231-360-1940
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 246ZC0007X
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Taxonomy Name | Surgical Assistant
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License Number | 175899
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License Number State |
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