Provider Demographics
NPI:1023311784
Name:CARSON TAHOE PHYSICIAN CLINICS - MINDEN #3
Entity type:Organization
Organization Name:CARSON TAHOE PHYSICIAN CLINICS - MINDEN #3
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:YOLANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROMO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-283-3096
Mailing Address - Street 1:2874 N CARSON ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89706-0251
Mailing Address - Country:US
Mailing Address - Phone:775-283-3096
Mailing Address - Fax:775-283-3091
Practice Address - Street 1:925 IRONWOOD DR
Practice Address - Street 2:SUITE 2105
Practice Address - City:MINDEN
Practice Address - State:NV
Practice Address - Zip Code:89423-5178
Practice Address - Country:US
Practice Address - Phone:775-445-7745
Practice Address - Fax:775-782-0073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-17
Last Update Date:2010-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV12752207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1568596229OtherNPI