Provider Demographics
NPI:1568665446
Name:SIERRA RECOVERY CENTER
Entity Type:Organization
Organization Name:SIERRA RECOVERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:FEDOR
Authorized Official - Suffix:
Authorized Official - Credentials:LADC
Authorized Official - Phone:530-541-5190
Mailing Address - Street 1:1137 EMERALD BAY RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-6207
Mailing Address - Country:US
Mailing Address - Phone:530-541-5190
Mailing Address - Fax:530-541-6031
Practice Address - Street 1:921 MACINAW RD # 4
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-3525
Practice Address - Country:US
Practice Address - Phone:530-541-5190
Practice Address - Fax:530-541-6031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-07
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA090003GN251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health