Healthcare Provider Details

I. General information

NPI: 1073707725
Provider Name (Legal Business Name): FIBROMYALGIA RELIEF CENTER OF LAKE TAHOE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2007
Last Update Date: 09/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

961 EMERALD BAY RD
SOUTH LAKE TAHOE CA
96150-6410
US

IV. Provider business mailing address

961 EMERALD BAY RD
SOUTH LAKE TAHOE CA
96150-6410
US

V. Phone/Fax

Practice location:
  • Phone: 530-543-1800
  • Fax: 530-544-0636
Mailing address:
  • Phone: 530-543-1800
  • Fax: 530-544-0636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number11681
License Number StateCA

VIII. Authorized Official

Name: PAUL E WHITCOMB
Title or Position: CHIROPRACTOR
Credential: DC
Phone: 530-318-8963