Healthcare Provider Details

I. General information

NPI: 1710496310
Provider Name (Legal Business Name): MEDALLUS & VACHAROTHONE LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2017
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 1ST AVE S UNIT A
JAMESTOWN ND
58401
US

IV. Provider business mailing address

721 A 1ST AVE SOUTH
JAMESTOWN ND
58401
US

V. Phone/Fax

Practice location:
  • Phone: 877-633-9110
  • Fax:
Mailing address:
  • Phone: 701-368-4380
  • Fax: 701-540-6818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: RACHOT VACHAROTHONE
Title or Position: CEO
Credential: MD
Phone: 801-260-1919