Healthcare Provider Details

I. General information

NPI: 1750372140
Provider Name (Legal Business Name): TAHOE FRACTURE & ORTHOPEDIC MEDICAL CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 10/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

973 MICA DR SUITE 201
CARSON CITY NV
89705-7255
US

IV. Provider business mailing address

973 MICA DR SUITE 201
CARSON CITY NV
89705-7255
US

V. Phone/Fax

Practice location:
  • Phone: 775-783-6190
  • Fax: 775-783-6191
Mailing address:
  • Phone: 775-783-6190
  • Fax: 775-783-6191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number1006
License Number StateNV
# 4
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JEFFREY CUMMINGS
Title or Position: PHYSICIAN/PARTNER
Credential: M.D.
Phone: 775-783-6190