Basic Information
| Provider Information | |||||||||
| NPI: | 1740724780 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DE CRAIG RANCH, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DIGNITY HEALTH ST ROSE DOMINICAN WEST FLAMINGO CAMPUS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8686 NEW TRAILS DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | THE WOODLANDS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773811176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136371146 | ||||||||
| FaxNumber: | 2812985311 | ||||||||
| Practice Location | |||||||||
| Address1: | 9880 W FLAMINGO RD | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136371146 | ||||||||
| FaxNumber: | 2812985311 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2016 | ||||||||
| LastUpdateDate: | 10/23/2018 | ||||||||
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| AuthorizedOfficialLastName: | BUCK | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7136371004 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DE CRAIG RANCH, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 1740724780 | 05 | NV | MEDICAID | 29-0058 | 01 | MEDICARE | OTHER |