Healthcare Provider Details

I. General information

NPI: 1851585947
Provider Name (Legal Business Name): TAHOE WOUND CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2007
Last Update Date: 08/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

865 TAHOE BLVD STE 113
INCLINE VILLAGE NV
89451-9449
US

IV. Provider business mailing address

865 TAHOE BLVD STE 113
INCLINE VILLAGE NV
89451-9449
US

V. Phone/Fax

Practice location:
  • Phone: 775-832-7200
  • Fax: 775-832-7201
Mailing address:
  • Phone: 775-832-7200
  • Fax: 775-832-7201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number07-3011
License Number StateNV

VIII. Authorized Official

Name: MR. DAVID I. MITTLEMAN
Title or Position: PRESIDENT AND OWNER
Credential:
Phone: 775-832-7200