MEDICARE: CLEMMENSEN, ADAMS, & TACK PSC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	207ND0101X	MOHS-Micrographic Surgery Physician
2	207ND0900X	Dermatopathology Physician
3	207NS0135X	Procedural Dermatology Physician
4	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1780852368
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLEMMENSEN, ADAMS, & TACK PSC

Provider Business Mailing Address
First Line	:	1100 S CARSON ST
Second Line	:
City	:	CARSON CITY
State	:	NV
Zip	:	89701-5232
Country	:	US
Telephone Number	:	775-883-7811
Fax Number	:	775-883-7871

Provider Business Practice Location Address
First Line	:	1100 S CARSON ST
Second Line	:
City	:	CARSON CITY
State	:	NV
Zip	:	89701-5232
Country	:	US
Telephone Number	:	775-883-7811
Fax Number	:	775-883-7871

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DAVID ALAN TACK
Credential	:	M.D.
Telephone Number	:	775-883-7811

Provider Enumeration Date	:	02/15/2008
Last Update Date	:	01/22/2015

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