Healthcare Provider Details

I. General information

NPI: 1487663795
Provider Name (Legal Business Name): AJEET MAHENDERNATH MD A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 05/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2505 ANTHEM VILLAGE DR STE E-603
HENDERSON NV
89052-5505
US

IV. Provider business mailing address

2505 ANTHEM VILLAGE DR STE E-603
HENDERSON NV
89052-5505
US

V. Phone/Fax

Practice location:
  • Phone: 702-453-3799
  • Fax: 702-453-5741
Mailing address:
  • Phone: 702-453-3799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9464
License Number StateNV

VIII. Authorized Official

Name: LORI A LABRECQUE
Title or Position: ACCTS. MGRE
Credential:
Phone: 702-453-3799