Provider Demographics
NPI:1386183911
Name:SANDY'S COUNTRY AFC
Entity Type:Organization
Organization Name:SANDY'S COUNTRY AFC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSEE/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:AMBRUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-868-0001
Mailing Address - Street 1:12955 68TH ST SE
Mailing Address - Street 2:
Mailing Address - City:ALTO
Mailing Address - State:MI
Mailing Address - Zip Code:49302-9741
Mailing Address - Country:US
Mailing Address - Phone:616-868-0001
Mailing Address - Fax:616-868-0030
Practice Address - Street 1:12955 68TH ST SE
Practice Address - Street 2:
Practice Address - City:ALTO
Practice Address - State:MI
Practice Address - Zip Code:49302-9741
Practice Address - Country:US
Practice Address - Phone:616-868-0001
Practice Address - Fax:616-868-0030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-15
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAM410281990311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI9455674Medicaid