=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215414636
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KREIS MEDICAL SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2018
-----------------------------------------------------
Last Update Date | 08/22/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 106 STAR RIDGE CIR
-----------------------------------------------------
City | MC GREGOR
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76657
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-744-7114
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 23148
-----------------------------------------------------
City | WACO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76702-3148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-744-7114
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. SIEGFRIED RICHARD KREIS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 254-744-7114
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | J2141
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------