Provider Demographics
NPI:1235789462
Name:SIERRA CARE AT THE LAKE,LLC
Entity Type:Organization
Organization Name:SIERRA CARE AT THE LAKE,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:PONTICIELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-539-2727
Mailing Address - Street 1:33425 GLOBE DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:93265
Mailing Address - Country:US
Mailing Address - Phone:559-539-2727
Mailing Address - Fax:559-553-8840
Practice Address - Street 1:33425 GLOBE DR
Practice Address - Street 2:
Practice Address - City:SPRINGVILLE
Practice Address - State:CA
Practice Address - Zip Code:93265
Practice Address - Country:US
Practice Address - Phone:559-539-2727
Practice Address - Fax:559-553-8840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-19
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
No315D00000XNursing & Custodial Care FacilitiesHospice, Inpatient