1396799102 NPI number — WASHOE BARTON MEDICAL CLINIC A NEVADA NONPROFIT CORPORATION

Table of content: (NPI 1396799102)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396799102 NPI number — WASHOE BARTON MEDICAL CLINIC A NEVADA NONPROFIT CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WASHOE BARTON MEDICAL CLINIC A NEVADA NONPROFIT CORPORATION
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:
Provider Other Organization Name Type Code:
6
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:
1396799102
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9578
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH LAKE TAHOE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
96158-9578
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-542-3000
Provider Business Mailing Address Fax Number:
530-541-2604

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1107 HWY 395
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARDNERVILLE
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-782-1500
Provider Business Practice Location Address Fax Number:
775-782-1555
Provider Enumeration Date:
05/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PRATER
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
K
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
775-782-1500

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 282NC0060X , 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)

  • Identifier: XH5P43645 . This is a "IN PATIENT" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 100502477 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100502479 . This is a "OUT PATIENT" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 100506873 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: XH5P33645 . This is a "OUT PATIENT" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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