Provider Demographics
NPI:1508265414
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:559-539-1100
Mailing Address - Street 1:33221 GLOBE DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:93265-9715
Mailing Address - Country:US
Mailing Address - Phone:559-539-1100
Mailing Address - Fax:559-539-1200
Practice Address - Street 1:33221 GLOBE DR
Practice Address - Street 2:A
Practice Address - City:SPRINGVILLE
Practice Address - State:CA
Practice Address - Zip Code:93265-9715
Practice Address - Country:US
Practice Address - Phone:559-539-1100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-15
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550003154311Z00000X, 313M00000X, 315D00000X
314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No315D00000XNursing & Custodial Care FacilitiesHospice, Inpatient