MEDICARE: RD PRABHU-LATA K SHETE MDS LTD

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	261QM1300X	Multi-Specialty Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	XGG00737	OTHER	CA	MEDI-CAL

General Provider Information

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

Provider Business Mailing Address
First Line	:	5701 W CHARLESTON BLVD
Second Line	:	SUITE 100
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-1217
Country	:	US
Telephone Number	:	702-877-9514
Fax Number	:	702-312-3510

Provider Business Practice Location Address
First Line	:	5701 W CHARLESTON BLVD
Second Line	:	SUITE 100
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-1217
Country	:	US
Telephone Number	:	702-877-9514
Fax Number	:	702-877-0399

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RACHAKONDA DAYANANDA PRABHU
Credential	:	MD
Telephone Number	:	702-877-9514

Provider Enumeration Date	:	10/10/2005
Last Update Date	:	08/22/2020

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