Provider Demographics
NPI:1679610158
Name:SIERRA INTEGRATED MEDICINE
Entity Type:Organization
Organization Name:SIERRA INTEGRATED MEDICINE
Other - Org Name:SIERRA INTEGRATIVE MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:KIRIN
Authorized Official - Last Name:FONG
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:775-828-5388
Mailing Address - Street 1:9333 DOUBLE R BLVD.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89521-2962
Mailing Address - Country:US
Mailing Address - Phone:775-828-5388
Mailing Address - Fax:775-828-6588
Practice Address - Street 1:9333 DOUBLE R BLVD.
Practice Address - Street 2:SUITE 100
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89521-2962
Practice Address - Country:US
Practice Address - Phone:775-828-5388
Practice Address - Fax:775-828-6588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV909207R00000X
NVNV0909207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty