Basic Information
| Provider Information | |||||||||
| NPI: | 1104971183 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARSON-TAHOE PATHOLOGY DRS JACK & DOBERNECK LTD | ||||||||
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| OtherOrganizationName: | DBA CARSON-TAHOE PATHOLOGY, LTD | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1633 ERRINGER ROAD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | SIMI VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8052978715 | ||||||||
| FaxNumber: | 8055783911 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 MEDICAL PKWY | ||||||||
| Address2: | |||||||||
| City: | CARSON CITY | ||||||||
| State: | NV | ||||||||
| PostalCode: | 897034625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7754458502 | ||||||||
| FaxNumber: | 7758884448 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2007 | ||||||||
| LastUpdateDate: | 12/18/2018 | ||||||||
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| AuthorizedOfficialLastName: | JACK | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 7754458502 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 5089 | NV | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.