Basic Information
| Provider Information | |||||||||
| NPI: | 1528594918 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TAHOE FRACTURE AND ORTHOPEDIC MEDICAL CLINIC,INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 973 MICA DR | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | CARSON CITY | ||||||||
| State: | NV | ||||||||
| PostalCode: | 897057255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757836190 | ||||||||
| FaxNumber: | 7757836191 | ||||||||
| Practice Location | |||||||||
| Address1: | 896 W NYE LN | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | CARSON CITY | ||||||||
| State: | NV | ||||||||
| PostalCode: | 897031578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757836190 | ||||||||
| FaxNumber: | 7757836191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2017 | ||||||||
| LastUpdateDate: | 05/04/2017 | ||||||||
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| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER / PROVIDER | ||||||||
| AuthorizedOfficialTelephone: | 7757836190 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.