Provider Demographics
NPI:1659831782
Name:SAFEWAY INDEPENDENT SERVICES, LLC
Entity Type:Organization
Organization Name:SAFEWAY INDEPENDENT SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:SHEREIF
Authorized Official - Last Name:SPRINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-962-4247
Mailing Address - Street 1:130 VILLAGE GREEN LN
Mailing Address - Street 2:
Mailing Address - City:SICKLERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08081-1641
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:130 VILLAGE GREEN LN
Practice Address - Street 2:
Practice Address - City:SICKLERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08081-1641
Practice Address - Country:US
Practice Address - Phone:718-962-4247
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-24
Last Update Date:2019-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty