Provider Demographics
NPI:1922542968
Name:DE CRAIG RANCH, LLC
Entity Type:Organization
Organization Name:DE CRAIG RANCH, LLC
Other - Org Name:DIGNITY HEALTH-ST. ROSE DOMINICAN BLUE DIAMOND CAMPUS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-637-1004
Mailing Address - Street 1:8686 NEW TRAILS DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77381-1176
Mailing Address - Country:US
Mailing Address - Phone:713-637-1146
Mailing Address - Fax:281-298-5311
Practice Address - Street 1:4855 BLUE DIAMOND RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89139
Practice Address - Country:US
Practice Address - Phone:713-637-1146
Practice Address - Fax:281-298-5311
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DE CRAIG RANCH, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-12-09
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1922542968Medicaid
29-0058OtherMEDICARE