Provider Demographics
NPI:1417577107
Name:SANA LAKE RECOVERY CENTER, LLC
Entity Type:Organization
Organization Name:SANA LAKE RECOVERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:GLENN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:314-392-3822
Mailing Address - Street 1:8350 STATE ROUTE 30
Mailing Address - Street 2:
Mailing Address - City:DITTMER
Mailing Address - State:MO
Mailing Address - Zip Code:63023
Mailing Address - Country:US
Mailing Address - Phone:314-392-3822
Mailing Address - Fax:
Practice Address - Street 1:150 SANA LAKE RECOVERY WAY
Practice Address - Street 2:
Practice Address - City:DITTMER
Practice Address - State:MO
Practice Address - Zip Code:63023
Practice Address - Country:US
Practice Address - Phone:636-944-4400
Practice Address - Fax:636-285-9574
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-22
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility