MEDICARE: LAKE TAHOE PODIATRY A PROFESSIONAL PODIATRIC CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213E00000X	Podiatrist	E3664	CA

General Provider Information

NPI Number	:	1396095881
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE TAHOE PODIATRY A PROFESSIONAL PODIATRIC CORPORATION

Provider Business Mailing Address
First Line	:	2229 BARTON AVE
Second Line	:
City	:	SOUTH LAKE TAHOE
State	:	CA
Zip	:	96150-3411
Country	:	US
Telephone Number	:	530-541-2665
Fax Number	:	530-541-2615

Provider Business Practice Location Address
First Line	:	2229 BARTON AVE
Second Line	:
City	:	SOUTH LAKE TAHOE
State	:	CA
Zip	:	96150-3411
Country	:	US
Telephone Number	:	530-541-2665
Fax Number	:	530-541-2615

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. PATRICIA L FERRARO
Credential	:	D.P.M.
Telephone Number	:	530-541-2665

Provider Enumeration Date	:	09/12/2012
Last Update Date	:	01/15/2013

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