Healthcare Provider Details

I. General information

NPI: 1790012789
Provider Name (Legal Business Name): SIERRA GARZA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2009
Last Update Date: 11/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 LANE 39
BURLINGTON WY
82411-9739
US

IV. Provider business mailing address

PO BOX 152
BURLINGTON WY
82411-0152
US

V. Phone/Fax

Practice location:
  • Phone: 307-272-6656
  • Fax:
Mailing address:
  • Phone: 307-272-6656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: