Healthcare Provider Details

I. General information

NPI: 1588895874
Provider Name (Legal Business Name): CARSON TAHOE PHYSICIAN CLINICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2009
Last Update Date: 08/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 IRONWOOD DR #2108
MINDEN NV
89423-5178
US

IV. Provider business mailing address

2874 N CARSON ST #200
CARSON CITY NV
89706-0251
US

V. Phone/Fax

Practice location:
  • Phone: 775-445-7929
  • Fax: 775-783-8889
Mailing address:
  • Phone: 775-883-9003
  • Fax: 775-883-0959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. MAGGIE L IVERSON
Title or Position: DIRECTOR
Credential: MBA, FACMPE
Phone: 775-283-3096