Basic Information
| Provider Information | |||||||||
| NPI: | 1295897395 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TAHOE FOREST HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | TAHOE FOREST HOSPITAL DP SNF | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 10121 PINE AVE | ||||||||
| Address2: | |||||||||
| City: | TRUCKEE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961614835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305876011 | ||||||||
| FaxNumber: | 5305823567 | ||||||||
| Practice Location | |||||||||
| Address1: | 10121 PINE AVE | ||||||||
| Address2: | |||||||||
| City: | TRUCKEE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961614835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305876011 | ||||||||
| FaxNumber: | 5305823567 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2006 | ||||||||
| LastUpdateDate: | 05/28/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BETTS | ||||||||
| AuthorizedOfficialFirstName: | CRYSTAL | ||||||||
| AuthorizedOfficialMiddleName: | NONE | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5305826656 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 230000151 | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.