Basic Information
| Provider Information | |||||||||
| NPI: | 1801084827 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SIERRA BLANCA CLINIC, LTD. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1210 | ||||||||
| Address2: | |||||||||
| City: | LAKESIDE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859291210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283680765 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2963 W WHITE MOUNTAIN BLVD | ||||||||
| Address2: | |||||||||
| City: | LAKESIDE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859296257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283680765 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2007 | ||||||||
| LastUpdateDate: | 12/27/2016 | ||||||||
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| AuthorizedOfficialLastName: | GARSKOF | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | MITCHELL | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9283680765 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 10885 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.