1003246612 NPI number — DARK KNIGHT TRUST

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003246612 NPI number — DARK KNIGHT TRUST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DARK KNIGHT TRUST
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:
1003246612
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
840 S RANCHO DR
Provider Second Line Business Mailing Address:
SUITE 4-410
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89106-3837
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-754-5700
Provider Business Mailing Address Fax Number:
702-982-8762

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
840 S RANCHO DR
Provider Second Line Business Practice Location Address:
SUITE 4-410
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89106-3837
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-754-5700
Provider Business Practice Location Address Fax Number:
702-982-8762
Provider Enumeration Date:
11/18/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WARD
Authorized Official First Name:
THERON
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO/COO
Authorized Official Telephone Number:
702-754-5701

Provider Taxonomy Codes

  • Taxonomy code: 171M00000X , with the licence number:  NV20121035663 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 246Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 253Z00000X , with the licence number: NV20121035663 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 311Z00000X , with the licence number: NV20121035663 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 343900000X , with the licence number: NV20121035663 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 374U00000X , with the licence number: NV20121035663 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251B00000X , with the licence number: NV20121035663 , 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: NV20121035663 . This is a "STATE OF NEVADA" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".