Healthcare Provider Details

I. General information

NPI: 1821081696
Provider Name (Legal Business Name): TRUCKEE TAHOE MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 05/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10956 DONNER PASS RD
TRUCKEE CA
96161-4861
US

IV. Provider business mailing address

PO BOX 68
TRUCKEE CA
96160-0068
US

V. Phone/Fax

Practice location:
  • Phone: 530-581-8864
  • Fax:
Mailing address:
  • Phone: 530-581-8864
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: NIKI HOLODAY
Title or Position: MANAGER
Credential:
Phone: 530-581-8864