Basic Information
| Provider Information | |||||||||
| NPI: | 1396799102 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WASHOE BARTON MEDICAL CLINIC A NEVADA NONPROFIT CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CARSON VALLEY MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9578 | ||||||||
| Address2: | |||||||||
| City: | SOUTH LAKE TAHOE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961589578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305423000 | ||||||||
| FaxNumber: | 5305412604 | ||||||||
| Practice Location | |||||||||
| Address1: | 1107 HWY 395 | ||||||||
| Address2: | |||||||||
| City: | GARDNERVILLE | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757821500 | ||||||||
| FaxNumber: | 7757821555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | PRATER | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7757821500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | NV | N | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical | 282NC0060X | NV | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | XH5P43645 | 01 | CA | IN PATIENT | OTHER | 100502477 | 05 | NV | MEDICAID | 100502479 | 01 | NV | OUT PATIENT | OTHER | 100506873 | 05 | NV | MEDICAID | XH5P33645 | 01 | CA | OUT PATIENT | OTHER |