Basic Information
| Provider Information | |||||||||
| NPI: | 1609937911 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKE TAHOE ORTHOPAEDIC INSTITUTE, A WATSON-SWANSON PROFESSIONAL CORP | ||||||||
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| OtherOrganizationName: | TAHOE ORTHOPEDICS AND SPORTS MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 EMERALD BAY RD | ||||||||
| Address2: | |||||||||
| City: | SOUTH LAKE TAHOE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961506207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305435659 | ||||||||
| FaxNumber: | 5305418723 | ||||||||
| Practice Location | |||||||||
| Address1: | 212 ELKS POINT RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | ZEPHYR COVE | ||||||||
| State: | NV | ||||||||
| PostalCode: | 894488001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7755898950 | ||||||||
| FaxNumber: | 7755881299 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2006 | ||||||||
| LastUpdateDate: | 05/10/2018 | ||||||||
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| AuthorizedOfficialLastName: | SWANSON | ||||||||
| AuthorizedOfficialFirstName: | KYLE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7757833065 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0106X | NV | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 207XX0005X | NV | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 208100000X | NV | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2081S0010X | NV | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Sports Medicine | 225X00000X | NV | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 363A00000X | NV | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207X00000X | NV | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.