Healthcare Provider Details

I. General information

NPI: 1366620601
Provider Name (Legal Business Name): REDROCK RENAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2008
Last Update Date: 02/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5751 S FORT APACHE RD SUITE 110
LAS VEGAS NV
89148-5624
US

IV. Provider business mailing address

5751 S FORT APACHE RD SUITE 110
LAS VEGAS NV
89148-5624
US

V. Phone/Fax

Practice location:
  • Phone: 702-586-0007
  • Fax: 702-586-0009
Mailing address:
  • Phone: 702-586-0007
  • Fax: 702-586-0009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. GALEN ROBERT BENNETT
Title or Position: ADMINISTRATOR, CEO
Credential: BMBA
Phone: 702-586-0007