=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578893202
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARSON TAHOE PHYSICIAN CLINICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/31/2009
-----------------------------------------------------
Last Update Date | 02/02/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 901 MEDICAL CENTER DR SUITE 102
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89403-7458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-445-7621
-----------------------------------------------------
Fax | 775-283-3091
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2874 N CARSON ST SUITE 200
-----------------------------------------------------
City | CARSON CITY
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89706-0251
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-283-3096
-----------------------------------------------------
Fax | 775-283-3091
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATIVE ASSIST
-----------------------------------------------------
Name | YOLANDA ROMO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 775-283-3096
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------