Basic Information
| Provider Information | |||||||||
| NPI: | 1396256293 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CRANIOM LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 575 LOS ALTOS CIR | ||||||||
| Address2: | |||||||||
| City: | MESQUITE | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890272523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013885390 | ||||||||
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| Practice Location | |||||||||
| Address1: | 575 LOS ALTOS CIR | ||||||||
| Address2: | |||||||||
| City: | MESQUITE | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890272523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013885390 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2017 | ||||||||
| LastUpdateDate: | 09/23/2021 | ||||||||
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| AuthorizedOfficialLastName: | TRITCHLER | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7013885390 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RPSGT, R.EPT, CNIM | ||||||||
| NPICertificationDate: | 09/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZE0600X | 3282 | N | 193400000X SINGLE SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Electroneurodiagnostic | 2084N0600X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology |
No ID Information.