=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326239591
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KREG THERAPEUTICS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2007
-----------------------------------------------------
Last Update Date | 08/05/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14200 WEST COMMERCE ROAD
-----------------------------------------------------
City | DALEVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-457-1408
-----------------------------------------------------
Fax | 312-829-8909
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14200 WEST COMMERCE ROAD
-----------------------------------------------------
City | DALEVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-457-1408
-----------------------------------------------------
Fax | 312-829-8909
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICARE BILLER SPECIALIST
-----------------------------------------------------
Name | MARIA I MAYORGA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 312-829-8904
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------