MEDICARE: CULINARY EXTRA CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1801295712
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CULINARY EXTRA CLINIC

Provider Business Mailing Address
First Line	:	101 TREMONT ST FL 6
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02108-5004
Country	:	US
Telephone Number	:	617-454-4672
Fax Number	:	617-701-7740

Provider Business Practice Location Address
First Line	:	1961 LAS VEGAS BLVD S STE 101
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-1310
Country	:	US
Telephone Number	:	702-852-0215
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	RUSHIKA FERNANDOPULLE
Credential	:	MD
Telephone Number	:	617-454-4672

Provider Enumeration Date	:	08/15/2014
Last Update Date	:	09/14/2015

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Directions to “CULINARY EXTRA CLINIC ” Practice Location

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