Provider Demographics
NPI:1730458258
Name:SIERRA DEVELOPMENTAL ENTERPRISE CORP
Entity Type:Organization
Organization Name:SIERRA DEVELOPMENTAL ENTERPRISE CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CLEMENTE
Authorized Official - Middle Name:
Authorized Official - Last Name:SIERRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-877-3198
Mailing Address - Street 1:10030 NICARAGUA DR
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33189-2337
Mailing Address - Country:US
Mailing Address - Phone:305-877-3198
Mailing Address - Fax:
Practice Address - Street 1:10030 NICARAGUA DR
Practice Address - Street 2:
Practice Address - City:CUTLER BAY
Practice Address - State:FL
Practice Address - Zip Code:33189-2337
Practice Address - Country:US
Practice Address - Phone:305-877-3198
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-29
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL690303796Medicaid