=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346458239
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KRAFT CENTER FOR PAIN CONTROL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2007
-----------------------------------------------------
Last Update Date | 02/12/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2650 CRIMSON CANYON DR
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89128-0841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-731-2642
-----------------------------------------------------
Fax | 702-791-2070
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2650 CRIMSON CANYON DR
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89128-0841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-731-2642
-----------------------------------------------------
Fax | 702-791-2070
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DEBRA FORD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 702-731-2642
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 58853
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------