Provider Demographics
NPI:1659361392
Name:SIERRA NEVADA MEMORIAL-MINERS HOSPITAL
Entity Type:Organization
Organization Name:SIERRA NEVADA MEMORIAL-MINERS HOSPITAL
Other - Org Name:SIERRA NEVADA MEMORIAL HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:CANADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-274-6099
Mailing Address - Street 1:3215 PROSPECT PARK DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-6017
Mailing Address - Country:US
Mailing Address - Phone:916-861-1102
Mailing Address - Fax:916-861-7707
Practice Address - Street 1:155 GLASSON WAY
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5723
Practice Address - Country:US
Practice Address - Phone:530-274-6000
Practice Address - Fax:530-274-6614
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SIERRA NEVADA MEMORIAL-MINERS HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-25
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA230000152282N00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACGP127135Medicaid
CAZZR00150FMedicaid
CAHSP40150FMedicaid
ZZZC2905ZOtherBLUE CROSS OF CA
CAMTE00374FMedicaid
ZZZC2905ZOtherBLUE CROSS OF CA
CAZZR00150FMedicaid
=========OtherIRS - TAX ID
CAHSP40150FMedicaid
=========959450000OtherWPS TRICARE