Provider Demographics
NPI:1386878767
Name:SIERRA WOUND CARE GROUP MEDICAL CORPORATION
Entity type:Organization
Organization Name:SIERRA WOUND CARE GROUP MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D./DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:EDEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-536-1785
Mailing Address - Street 1:680 GUZZI LN
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-5288
Mailing Address - Country:US
Mailing Address - Phone:209-536-1785
Mailing Address - Fax:209-536-1607
Practice Address - Street 1:12811 COVEY CIR
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-5935
Practice Address - Country:US
Practice Address - Phone:209-536-1785
Practice Address - Fax:209-536-1607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-13
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty