Basic Information
| Provider Information | |||||||||
| NPI: | 1912995309 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RD PRABHU-LATA K SHETE MDS LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5701 W CHARLESTON BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891461217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028779514 | ||||||||
| FaxNumber: | 7023123510 | ||||||||
| Practice Location | |||||||||
| Address1: | 5701 W CHARLESTON BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891461217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028779514 | ||||||||
| FaxNumber: | 7028770399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | PRABHU | ||||||||
| AuthorizedOfficialFirstName: | RACHAKONDA | ||||||||
| AuthorizedOfficialMiddleName: | DAYANANDA | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7028779514 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 100506357 | 05 | NV | MEDICAID | XGG00737 | 01 | CA | MEDI-CAL | OTHER |