Healthcare Provider Details

I. General information

NPI: 1235789462
Provider Name (Legal Business Name): SIERRA CARE AT THE LAKE,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2019
Last Update Date: 09/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33425 GLOBE DR
SPRINGVILLE CA
93265
US

IV. Provider business mailing address

33425 GLOBE DR
SPRINGVILLE CA
93265
US

V. Phone/Fax

Practice location:
  • Phone: 559-539-2727
  • Fax: 559-553-8840
Mailing address:
  • Phone: 559-539-2727
  • Fax: 559-553-8840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code315D00000X
TaxonomyInpatient Hospice
License Number
License Number State

VIII. Authorized Official

Name: GARY ANDREW PONTICIELLO
Title or Position: PRESIDENT
Credential:
Phone: 559-539-2727