Provider Demographics
NPI:1497936694
Name:MOUNTAIN MEADOWS MEDICAL GROUP OF CALIFORNIA, INC.
Entity Type:Organization
Organization Name:MOUNTAIN MEADOWS MEDICAL GROUP OF CALIFORNIA, INC.
Other - Org Name:TAHOE WOMEN'S CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KRIS
Authorized Official - Middle Name:F
Authorized Official - Last Name:KOBALTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:530-543-5710
Mailing Address - Street 1:1067 4TH ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-3459
Mailing Address - Country:US
Mailing Address - Phone:530-543-5710
Mailing Address - Fax:530-542-1455
Practice Address - Street 1:973 MICA DR STE 200
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89705-7258
Practice Address - Country:US
Practice Address - Phone:775-267-6700
Practice Address - Fax:775-267-6609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-16
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV32113Medicare PIN