Provider Demographics
NPI:1396799102
Name:WASHOE BARTON MEDICAL CLINIC A NEVADA NONPROFIT CORPORATION
Entity type:Organization
Organization Name:WASHOE BARTON MEDICAL CLINIC A NEVADA NONPROFIT CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:K
Authorized Official - Last Name:PRATER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-782-1500
Mailing Address - Street 1:PO BOX 9578
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96158-9578
Mailing Address - Country:US
Mailing Address - Phone:530-542-3000
Mailing Address - Fax:530-541-2604
Practice Address - Street 1:1107 HWY 395
Practice Address - Street 2:
Practice Address - City:GARDNERVILLE
Practice Address - State:NV
Practice Address - Zip Code:89410
Practice Address - Country:US
Practice Address - Phone:775-782-1500
Practice Address - Fax:775-782-1555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV261QA1903X, 282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXH5P43645OtherIN PATIENT
NV100502477Medicaid
NV100502479OtherOUT PATIENT
NV100506873Medicaid
CAXH5P33645OtherOUT PATIENT
NV100502477Medicaid