Provider Demographics
NPI:1174708879
Name:CARSON VALLEY MEDICAL CENTER RURAL HEALTH CLINIC
Entity type:Organization
Organization Name:CARSON VALLEY MEDICAL CENTER RURAL HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:PRATER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-782-1500
Mailing Address - Street 1:1520 VIRGINIA RANCH ROAD
Mailing Address - Street 2:
Mailing Address - City:GARDNERVILLE
Mailing Address - State:NV
Mailing Address - Zip Code:89410-5731
Mailing Address - Country:US
Mailing Address - Phone:775-782-1550
Mailing Address - Fax:775-782-1513
Practice Address - Street 1:1520 VIRGINIA RANCH RD
Practice Address - Street 2:
Practice Address - City:GARDNERVILLE
Practice Address - State:NV
Practice Address - Zip Code:89410-5731
Practice Address - Country:US
Practice Address - Phone:775-782-1550
Practice Address - Fax:775-782-1513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-01
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV105788Medicare PIN