Basic Information
| Provider Information | |||||||||
| NPI: | 1659692556 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRUCKEE TAHOE MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10115 W RIVER ST | ||||||||
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| City: | TRUCKEE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961610324 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 925 N LAKE BLVD | ||||||||
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| City: | TAHOE CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 96145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305818864 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2010 | ||||||||
| LastUpdateDate: | 06/15/2010 | ||||||||
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| AuthorizedOfficialLastName: | HOLODAY | ||||||||
| AuthorizedOfficialFirstName: | NIKI | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5305818864 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A68375 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.