Provider Demographics
NPI:1023368883
Name:TAHOE FRACTURE AND ORTHOPEDIC MEDICAL CLINIC, INC.
Entity Type:Organization
Organization Name:TAHOE FRACTURE AND ORTHOPEDIC MEDICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:775-783-6190
Mailing Address - Street 1:973 MICA DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89705-7255
Mailing Address - Country:US
Mailing Address - Phone:775-783-6190
Mailing Address - Fax:775-783-6191
Practice Address - Street 1:1520 VIRGINIA RANCH RD
Practice Address - Street 2:SUITE 101B
Practice Address - City:GARDNERVILLE
Practice Address - State:NV
Practice Address - Zip Code:89410-5731
Practice Address - Country:US
Practice Address - Phone:775-782-2442
Practice Address - Fax:775-783-6199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-19
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
0478150004Medicare NSC