Provider Demographics
NPI:1598962045
Name:SONORA COMMUNITY HOSPITAL
Entity Type:Organization
Organization Name:SONORA COMMUNITY HOSPITAL
Other - Org Name:SIERRA VASCULAR CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT FOR FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-536-5011
Mailing Address - Street 1:14542 LOLLY LN
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-9226
Mailing Address - Country:US
Mailing Address - Phone:209-536-2760
Mailing Address - Fax:209-533-7696
Practice Address - Street 1:680 GUZZI LN
Practice Address - Street 2:STE 104
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-5288
Practice Address - Country:US
Practice Address - Phone:209-536-5090
Practice Address - Fax:209-536-3585
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SONORA COMMUNITY HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-28
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA050335Medicare Oscar/Certification
CACU0092Medicare PIN