MEDICARE: KRISMA DESPORTES

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	133V00000X	Registered Dietitian	133V00000X	NV

General Provider Information

NPI Number	:	1427141449
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISMA DESPORTES

Provider Business Mailing Address
First Line	:	4700 LAS VEGAS BLVD N
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89191-6600
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4700 NORTH LAS VEGAS BLVD
Second Line	:
City	:	NELLIS AFB
State	:	NV
Zip	:	89115-2329
Country	:	US
Telephone Number	:	702-653-2901
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/02/2006
Last Update Date	:	07/22/2009

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Directions to “ KRISMA DESPORTES ” Practice Location

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