=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386878767
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SIERRA WOUND CARE GROUP MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2009
-----------------------------------------------------
Last Update Date | 05/13/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12811 COVEY CIR
-----------------------------------------------------
City | SONORA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95370-5935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-536-1785
-----------------------------------------------------
Fax | 209-536-1607
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 680 GUZZI LN SUITE 201
-----------------------------------------------------
City | SONORA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95370-5288
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-536-1785
-----------------------------------------------------
Fax | 209-536-1607
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | M.D./DIRECTOR
-----------------------------------------------------
Name | DR. EDEN L SMITH
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 209-536-1785
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------