1104971183 NPI number — CARSON-TAHOE PATHOLOGY DRS JACK & DOBERNECK LTD

Table of content: (NPI 1104971183)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104971183 NPI number — CARSON-TAHOE PATHOLOGY DRS JACK & DOBERNECK LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CARSON-TAHOE PATHOLOGY DRS JACK & DOBERNECK LTD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DBA CARSON-TAHOE PATHOLOGY, LTD
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104971183
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1633 ERRINGER RD STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIMI VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93065-3580
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-250-5764
Provider Business Mailing Address Fax Number:
805-578-3911

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 MEDICAL PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARSON CITY
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89703-4625
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-250-5764
Provider Business Practice Location Address Fax Number:
775-888-4448
Provider Enumeration Date:
01/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JACK
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
775-445-8502

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  5089 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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