MEDICARE: SIERRA ORTHOPEDIC LABORATORY, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	335E00000X	Prosthetic/Orthotic Supplier

General Provider Information

NPI Number	:	1417578121
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SIERRA ORTHOPEDIC LABORATORY, INC.

Provider Business Mailing Address
First Line	:	PO BOX 1848
Second Line	:
City	:	NOVATO
State	:	CA
Zip	:	94948-1848
Country	:	US
Telephone Number	:	707-528-9808
Fax Number	:	707-528-9818

Provider Business Practice Location Address
First Line	:	157 LYNCH CREEK WAY
Second Line	:
City	:	PETALUMA
State	:	CA
Zip	:	94954-2342
Country	:	US
Telephone Number	:	707-528-9808
Fax Number	:	707-528-9818

Authorized Official
Title or Position	:	OWNER
Name	:	DAVID JOHN JEFFRIES
Credential	:	C.O.
Telephone Number	:	707-528-9808

Provider Enumeration Date	:	05/04/2020
Last Update Date	:	11/18/2021

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