Provider Demographics
NPI:1073707725
Name:FIBROMYALGIA RELIEF CENTER OF LAKE TAHOE
Entity Type:Organization
Organization Name:FIBROMYALGIA RELIEF CENTER OF LAKE TAHOE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:E
Authorized Official - Last Name:WHITCOMB
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:530-318-8963
Mailing Address - Street 1:961 EMERALD BAY RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-6410
Mailing Address - Country:US
Mailing Address - Phone:530-543-1800
Mailing Address - Fax:530-544-0636
Practice Address - Street 1:961 EMERALD BAY RD
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-6410
Practice Address - Country:US
Practice Address - Phone:530-543-1800
Practice Address - Fax:530-544-0636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-05
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11681305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service