Healthcare Provider Details

I. General information

NPI: 1912995309
Provider Name (Legal Business Name): RD PRABHU-LATA K SHETE MDS LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5701 W CHARLESTON BLVD SUITE 100
LAS VEGAS NV
89146-1217
US

IV. Provider business mailing address

5701 W CHARLESTON BLVD SUITE 100
LAS VEGAS NV
89146-1217
US

V. Phone/Fax

Practice location:
  • Phone: 702-877-9514
  • Fax: 702-877-0399
Mailing address:
  • Phone: 702-877-9514
  • Fax: 702-312-3510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RACHAKONDA DAYANANDA PRABHU
Title or Position: PRESIDENT
Credential: MD
Phone: 702-877-9514