Provider Demographics
NPI:1457652448
Name:KDTK CORP LLC
Entity Type:Organization
Organization Name:KDTK CORP LLC
Other - Org Name:DOLCRX WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:KHANH
Authorized Official - Middle Name:BAO
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:RPH,CDE
Authorized Official - Phone:702-436-5279
Mailing Address - Street 1:PO BOX 35668
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5668
Mailing Address - Country:US
Mailing Address - Phone:702-436-5279
Mailing Address - Fax:702-776-8201
Practice Address - Street 1:801 S RANCHO DR
Practice Address - Street 2:SUITE A4
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-3854
Practice Address - Country:US
Practice Address - Phone:702-436-5279
Practice Address - Fax:702-776-8201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-08
Last Update Date:2018-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV332B00000X332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies