1699719419 NPI number — SIERRA NEVADA PRIMARY CARE

Table of content: (NPI 1699719419)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699719419 NPI number — SIERRA NEVADA PRIMARY CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SIERRA NEVADA PRIMARY CARE
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:
SIERRA CARE PHYSICIANS
Provider Other Organization Name Type Code:
3
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:
1699719419
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/12/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 459001
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRASS VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95945-9101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-265-7833
Provider Business Mailing Address Fax Number:
530-470-1821

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
140 LITTON DR STE 110
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRASS VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95945-5078
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-272-9770
Provider Business Practice Location Address Fax Number:
530-272-9796
Provider Enumeration Date:
06/15/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WAGNER
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT, BOARD OF DIRECTORS
Authorized Official Telephone Number:
530-272-9791

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  20A79401 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: 20A7977 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: G55765 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: G13927 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: G61414 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: A71856 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: G23768 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: G35403 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: A26753 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: G34453 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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