Healthcare Provider Details

I. General information

NPI: 1396256293
Provider Name (Legal Business Name): CRANIOM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2017
Last Update Date: 09/23/2021
Certification Date: 09/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 LOS ALTOS CIR
MESQUITE NV
89027-2523
US

IV. Provider business mailing address

575 LOS ALTOS CIR
MESQUITE NV
89027-2523
US

V. Phone/Fax

Practice location:
  • Phone: 701-388-5390
  • Fax:
Mailing address:
  • Phone: 701-388-5390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number3282
License Number State

VIII. Authorized Official

Name: JAMES TRITCHLER
Title or Position: MANAGER
Credential: RPSGT, R.EPT, CNIM
Phone: 701-388-5390