Provider Demographics
NPI:1568882991
Name:SIERRA BLANCA REHABILITATION LLC
Entity Type:Organization
Organization Name:SIERRA BLANCA REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:K
Authorized Official - Last Name:MEYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-652-5628
Mailing Address - Street 1:3401 LOCKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929-5613
Mailing Address - Country:US
Mailing Address - Phone:928-368-2060
Mailing Address - Fax:928-368-2085
Practice Address - Street 1:3401 LOCKWOOD DR
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929-5613
Practice Address - Country:US
Practice Address - Phone:928-368-2060
Practice Address - Fax:928-368-2085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-24
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZNCI 2691314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ573045Medicaid
AZ035722OtherMEDICARE PTAN