Provider Demographics
NPI:1043788359
Name:SOUTH LAKE TAHOE RECOVERY AND REHABILITATION, LLC
Entity Type:Organization
Organization Name:SOUTH LAKE TAHOE RECOVERY AND REHABILITATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TUDDENHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:831-740-4629
Mailing Address - Street 1:262 GAFFEY RD
Mailing Address - Street 2:
Mailing Address - City:WATSONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95076-9731
Mailing Address - Country:US
Mailing Address - Phone:831-740-4629
Mailing Address - Fax:831-708-2450
Practice Address - Street 1:591 TAHOE KEYS BLVD STE D2
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-3359
Practice Address - Country:US
Practice Address - Phone:530-539-9029
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-05
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder