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General NPI Number Information
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NPI Number | 1205802279
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Entity Type | Organization
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Legal Business Name | CRISTO REY HEALTHCARE, LLC
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Dates
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Enumeration Date | 02/28/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 907A E JESUIT LN
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City | ST MARYS
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State | KS
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Zip | 66536-9605
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Country | US
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Telephone | 785-437-3711
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Fax | 785-437-6711
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Provider Business Mailing Address
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Address Line | 907A E JESUIT LN
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City | ST MARYS
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State | KS
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Zip | 66536-9605
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Country | US
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Telephone | 785-437-3711
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Fax | 785-437-6711
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. CARL BRUCE CARROLL
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Credential | M.D.
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Telephone | 785-437-3711
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 04-23089
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License Number State | KS
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