1336799170 NPI number — SIERRA CARE AT THE LAKE,LLC

Table of content: (NPI 1598950784)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336799170 NPI number — SIERRA CARE AT THE LAKE,LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SIERRA CARE AT THE LAKE,LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336799170
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
648 W SIERRA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLOVIS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93612-0151
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-325-6100
Provider Business Mailing Address Fax Number:
559-553-8840

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
648 W SIERRA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLOVIS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93612-0151
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-325-6100
Provider Business Practice Location Address Fax Number:
559-553-8840
Provider Enumeration Date:
09/13/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PONTICIELLO
Authorized Official First Name:
GARY
Authorized Official Middle Name:
ANDREW
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
559-539-2727

Provider Taxonomy Codes

  • Taxonomy code: 311Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 313M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 315D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)