=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558525501
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SIERRA CHIROPRACTIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2008
-----------------------------------------------------
Last Update Date | 07/17/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3670 GRANT DR SUITE 101
-----------------------------------------------------
City | RENO
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89509-5309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-852-3333
-----------------------------------------------------
Fax | 775-322-0606
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3670 GRANT DR SUITE 101
-----------------------------------------------------
City | RENO
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89509-5309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-852-3333
-----------------------------------------------------
Fax | 775-322-0606
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | DR. GERALD L EDWARDS
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 775-852-3333
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | B02006
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------