Provider Demographics
NPI:1164671798
Name:LAKE TAHOE ORTHOPAEDIC INSTITUTE
Entity Type:Organization
Organization Name:LAKE TAHOE ORTHOPAEDIC INSTITUTE
Other - Org Name:DME - INCLINE VILLAGE
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BANNAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:530-541-3100
Mailing Address - Street 1:1111 EMERALD BAY RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-6207
Mailing Address - Country:US
Mailing Address - Phone:530-543-5659
Mailing Address - Fax:530-541-8723
Practice Address - Street 1:925 TAHOE BLVD STE 105
Practice Address - Street 2:
Practice Address - City:INCLINE VILLAGE
Practice Address - State:NV
Practice Address - Zip Code:89451-7498
Practice Address - Country:US
Practice Address - Phone:775-580-7600
Practice Address - Fax:775-831-7336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-18
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV5831810002Medicare NSC