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General NPI Number Information
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NPI Number | 1972017549
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Entity Type | Organization
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Legal Business Name | PSYCHOPHYLAXIS INSTITUTE LLC
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Dates
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Enumeration Date | 11/18/2017
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Last Update Date | 11/18/2017
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Provider Practice Location Address
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Address Line | 2470 E FLAMINGO RD STE D
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City | LAS VEGAS
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State | NV
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Zip | 89121-5200
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Country | US
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Telephone | 702-544-3849
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Fax |
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Provider Business Mailing Address
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Address Line | 164 W INVITAR LN
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City | MOUNTAIN HOUSE
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State | CA
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Zip | 95391-2036
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Country | US
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Telephone | 646-688-3579
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MUDALODU VASUDEVAN
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Credential |
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Telephone | 646-688-3579
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 4301102270
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 17489
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License Number State | NV
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