Provider Demographics
NPI:1902435894
Name:SLT MEDICAL GROUP INC
Entity Type:Organization
Organization Name:SLT MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:EMMANUEL
Authorized Official - Last Name:NEBBLETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:575-654-5188
Mailing Address - Street 1:PO BOX 910
Mailing Address - Street 2:
Mailing Address - City:WEIMAR
Mailing Address - State:CA
Mailing Address - Zip Code:95736-0910
Mailing Address - Country:US
Mailing Address - Phone:575-654-5188
Mailing Address - Fax:
Practice Address - Street 1:2024 LAKE TAHOE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-6498
Practice Address - Country:US
Practice Address - Phone:406-334-7470
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-03
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health