MEDICARE: TRINA SANFORD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320800000X	Mental Illness Community Based Residential Treatment Facility	374601272	CA

General Provider Information

NPI Number	:	1518310739
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRINA SANFORD

Provider Business Mailing Address
First Line	:	9490 LOS COCHES CT
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92508-6814
Country	:	US
Telephone Number	:	951-966-6515
Fax Number	:	760-724-0309

Provider Business Practice Location Address
First Line	:	9490 LOS COCHES CT
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92508-6814
Country	:	US
Telephone Number	:	951-966-6515
Fax Number	:	760-724-0309

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/22/2016
Last Update Date	:	07/22/2016

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