MEDICARE: NAMI EL DORADO COUNTY WESTERN SLOPE AND SOUTH LAKE TAHOE

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	261QR0400X	Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1780543967
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NAMI EL DORADO COUNTY WESTERN SLOPE AND SOUTH LAKE TAHOE

Provider Business Mailing Address
First Line	:	471 PIERROZ RD
Second Line	:
City	:	PLACERVILLE
State	:	CA
Zip	:	95667-4043
Country	:	US
Telephone Number	:	530-306-4101
Fax Number	:

Provider Business Practice Location Address
First Line	:	471 PIERROZ RD
Second Line	:
City	:	PLACERVILLE
State	:	CA
Zip	:	95667-4043
Country	:	US
Telephone Number	:	530-306-4101
Fax Number	:

Authorized Official
Title or Position	:	TREASURER
Name	:	ROBERT ALLEN LANDRY
Credential	:
Telephone Number	:	916-606-0999

Provider Enumeration Date	:	01/21/2026
Last Update Date	:	01/21/2026

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