MEDICARE: ELLESTON CRAIG RUCKER 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	207R00000X	Internal Medicine Physician	6766	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1669969754
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELLESTON CRAIG RUCKER LLC

Provider Business Mailing Address
First Line	:	811 S DECATUR BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89107-3933
Country	:	US
Telephone Number	:	702-439-5283
Fax Number	:

Provider Business Practice Location Address
First Line	:	811 S DECATUR BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89107-3933
Country	:	US
Telephone Number	:	702-439-5283
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ELLESTON CRAIG RUCKER
Credential	:	MD
Telephone Number	:	702-439-5283

Provider Enumeration Date	:	04/16/2018
Last Update Date	:	04/16/2018

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