=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922542968
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DE CRAIG RANCH, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2016
-----------------------------------------------------
Last Update Date | 10/23/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4855 BLUE DIAMOND RD
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-637-1146
-----------------------------------------------------
Fax | 281-298-5311
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8686 NEW TRAILS DR SUITE 100
-----------------------------------------------------
City | THE WOODLANDS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77381-1176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-637-1146
-----------------------------------------------------
Fax | 281-298-5311
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JOHN BUCK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 713-637-1004
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282N00000X
-----------------------------------------------------
Taxonomy Name | General Acute Care Hospital
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------