Provider Demographics
NPI:1619126240
Name:LAKE TAHOE ORTHOPAEDIC INSTITUTE A WATSON-SWANSON PROFESSIONAL CORP
Entity Type:Organization
Organization Name:LAKE TAHOE ORTHOPAEDIC INSTITUTE A WATSON-SWANSON PROFESSIONAL CORP
Other - Org Name:DME - CARSON CITY
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:E
Authorized Official - Last Name:SWANSON
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 1:935 MICA DR STE 13
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89705-7181
Practice Address - Country:US
Practice Address - Phone:775-783-3065
Practice Address - Fax:775-267-1829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-18
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV5831810007Medicare NSC