Provider Demographics
NPI:1295716454
Name:SIERRA LAND
Entity type:Organization
Organization Name:SIERRA LAND
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:DOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-977-6532
Mailing Address - Street 1:12207 N 113TH AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGTOWN
Mailing Address - State:AZ
Mailing Address - Zip Code:85363-1208
Mailing Address - Country:US
Mailing Address - Phone:623-977-6532
Mailing Address - Fax:623-977-6541
Practice Address - Street 1:12207 N 113TH AVE
Practice Address - Street 2:
Practice Address - City:YOUNGTOWN
Practice Address - State:AZ
Practice Address - Zip Code:85363-1208
Practice Address - Country:US
Practice Address - Phone:623-977-6532
Practice Address - Fax:623-977-6541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-07
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZNCI-1504314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ538233-.01Medicaid
AZAZ0401440OtherBLUECROSS BLUE SHIELD
AZ03-5245Medicare ID - Type UnspecifiedMEDICARE