Provider Demographics
NPI:1356882898
Name:SIERRA WATSON
Entity type:Organization
Organization Name:SIERRA WATSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SIERRA
Authorized Official - Middle Name:
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-886-1384
Mailing Address - Street 1:12610 US HIGHWAY 129
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:FL
Mailing Address - Zip Code:32060-6753
Mailing Address - Country:US
Mailing Address - Phone:678-886-1384
Mailing Address - Fax:386-208-0002
Practice Address - Street 1:12610 US HIGHWAY 129
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:FL
Practice Address - Zip Code:32060-6753
Practice Address - Country:US
Practice Address - Phone:678-886-1384
Practice Address - Fax:386-208-0002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-16
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6906883311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019424000Medicaid