MEDICARE: DE CRAIG RANCH LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	282N00000X	General Acute Care Hospital

General Provider Information

NPI Number	:	1073329223
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DE CRAIG RANCH LLC

Provider Business Mailing Address
First Line	:	8686 NEW TRAILS DR STE 100
Second Line	:
City	:	THE WOODLANDS
State	:	TX
Zip	:	77381-1195
Country	:	US
Telephone Number	:	713-929-2076
Fax Number	:

Provider Business Practice Location Address
First Line	:	6675 N DURANGO DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89149-4430
Country	:	US
Telephone Number	:	713-929-2076
Fax Number	:

Authorized Official
Title or Position	:	SR MED STAFF ENROLLMENT COORDINATOR
Name	:	TINA JOHNSON
Credential	:
Telephone Number	:	713-929-2076

Provider Enumeration Date	:	12/03/2024
Last Update Date	:	01/29/2026

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