Healthcare Provider Details

I. General information

NPI: 1972630432
Provider Name (Legal Business Name): MOUNTAIN MEADOWS MEDICAL GROUP OF CALIFORNIA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 09/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1067 4TH ST
S LAKE TAHOE CA
96150-3459
US

IV. Provider business mailing address

1067 4TH ST
S LAKE TAHOE CA
96150-3459
US

V. Phone/Fax

Practice location:
  • Phone: 530-543-5710
  • Fax: 530-542-1455
Mailing address:
  • Phone: 530-543-5710
  • Fax: 530-542-1455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number207V00000X
License Number StateCA

VIII. Authorized Official

Name: DR. KRIS F KOBALTER
Title or Position: VICE PRESIDENT
Credential: MD
Phone: 530-543-5710