1922542968 NPI number — DE CRAIG RANCH, LLC

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 1922542968 NPI number — DE CRAIG RANCH, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DE CRAIG RANCH, LLC
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:
1922542968
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/23/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8686 NEW TRAILS DR
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
THE WOODLANDS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77381-1176
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-637-1146
Provider Business Mailing Address Fax Number:
281-298-5311

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4855 BLUE DIAMOND RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89139
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-637-1146
Provider Business Practice Location Address Fax Number:
281-298-5311
Provider Enumeration Date:
12/09/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BUCK
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
713-637-1004

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1922542968 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 29-0058 . This is a "MEDICARE" identifier . This identifiers is of the category "OTHER".




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