Provider Demographics
NPI:1851794853
Name:TRIVEDA HEALTH
Entity Type:Organization
Organization Name:TRIVEDA HEALTH
Other - Org Name:ELEVATE WELLNESS
Other - Org Type:Other Name
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:PITTLICK
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:775-219-9076
Mailing Address - Street 1:2244 BARTON AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-3408
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2244 BARTON AVE
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-3408
Practice Address - Country:US
Practice Address - Phone:530-541-9355
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-03
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP13943261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care