Healthcare Provider Details

I. General information

NPI: 1043640097
Provider Name (Legal Business Name): KRIS BUXENBAUM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2013
Last Update Date: 11/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4310 CAMERON ST
LAS VEGAS NV
89103-3826
US

IV. Provider business mailing address

5230 W PATRICK LN STE 140
LAS VEGAS NV
89118-5852
US

V. Phone/Fax

Practice location:
  • Phone: 702-570-5100
  • Fax: 702-570-5104
Mailing address:
  • Phone: 702-570-5100
  • Fax: 702-570-5104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: