MEDICARE: SIERRA INTEGRATED MEDICINE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	909	NV
2	207R00000X	Internal Medicine Physician	NV0909	NV

General Provider Information

NPI Number	:	1679610158
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SIERRA INTEGRATED MEDICINE

Provider Business Mailing Address
First Line	:	9333 DOUBLE R BLVD.
Second Line	:	SUITE 100
City	:	RENO
State	:	NV
Zip	:	89521-2962
Country	:	US
Telephone Number	:	775-828-5388
Fax Number	:	775-828-6588

Provider Business Practice Location Address
First Line	:	9333 DOUBLE R BLVD.
Second Line	:	SUITE 100
City	:	RENO
State	:	NV
Zip	:	89521-2962
Country	:	US
Telephone Number	:	775-828-5388
Fax Number	:	775-828-6588

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	DR. BRUCE KIRIN FONG
Credential	:	D.O.
Telephone Number	:	775-828-5388

Provider Enumeration Date	:	01/31/2007
Last Update Date	:	11/18/2014

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Directions to “SIERRA INTEGRATED MEDICINE ” Practice Location

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