Provider Demographics
NPI:1760440515
Name:SIERRA ENDOSCOPY CENTER, LLC
Entity Type:Organization
Organization Name:SIERRA ENDOSCOPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:BOON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-567-0269
Mailing Address - Street 1:300 SIERRA COLLEGE DR
Mailing Address - Street 2:STE.105
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-5082
Mailing Address - Country:US
Mailing Address - Phone:530-273-0527
Mailing Address - Fax:
Practice Address - Street 1:300 SIERRA COLLEGE DR
Practice Address - Street 2:STE.105
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5082
Practice Address - Country:US
Practice Address - Phone:530-273-0527
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA230000350261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ23460ZMedicare ID - Type Unspecified