Provider Demographics
NPI:1063953537
Name:TAHOE FRACTURE AND ORTHOPEDIC MEDICAL CLINIC, INC
Entity type:Organization
Organization Name:TAHOE FRACTURE AND ORTHOPEDIC MEDICAL CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:775-783-6190
Mailing Address - Street 1:973 MICA DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89705-7255
Mailing Address - Country:US
Mailing Address - Phone:775-783-6190
Mailing Address - Fax:775-783-6191
Practice Address - Street 1:1749 N STEWART ST # C
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89706-2688
Practice Address - Country:US
Practice Address - Phone:775-783-6190
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-16
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies