Healthcare Provider Details

I. General information

NPI: 1659366003
Provider Name (Legal Business Name): SIERRA ORTHOPEDIC LABORATORY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 03/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4847 OLD REDWOOD HWY
SANTA ROSA CA
95403-1415
US

IV. Provider business mailing address

4847 OLD REDWOOD HWY
SANTA ROSA CA
95403-1415
US

V. Phone/Fax

Practice location:
  • Phone: 707-528-9808
  • Fax: 707-528-9818
Mailing address:
  • Phone: 707-528-9808
  • Fax: 707-528-9818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID JOHN JEFFRIES
Title or Position: OWNER
Credential: C.O.
Phone: 707-528-9808