Healthcare Provider Details

I. General information

NPI: 1780852368
Provider Name (Legal Business Name): CLEMMENSEN, ADAMS, & TACK PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2008
Last Update Date: 01/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 S CARSON ST
CARSON CITY NV
89701-5232
US

IV. Provider business mailing address

1100 S CARSON ST
CARSON CITY NV
89701-5232
US

V. Phone/Fax

Practice location:
  • Phone: 775-883-7811
  • Fax: 775-883-7871
Mailing address:
  • Phone: 775-883-7811
  • Fax: 775-883-7871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID ALAN TACK
Title or Position: PRESIDENT
Credential: M.D.
Phone: 775-883-7811