Provider Demographics
NPI:1780852368
Name:CLEMMENSEN, ADAMS, & TACK PSC
Entity Type:Organization
Organization Name:CLEMMENSEN, ADAMS, & TACK PSC
Other - Org Name:CARSON DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:TACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:775-883-7811
Mailing Address - Street 1:1100 S CARSON ST
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89701-5232
Mailing Address - Country:US
Mailing Address - Phone:775-883-7811
Mailing Address - Fax:775-883-7871
Practice Address - Street 1:1100 S CARSON ST
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89701-5232
Practice Address - Country:US
Practice Address - Phone:775-883-7811
Practice Address - Fax:775-883-7871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-15
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty