Provider Demographics
NPI:1790493401
Name:MEDELLA FAMILY CLINIC LLC
Entity Type:Organization
Organization Name:MEDELLA FAMILY CLINIC LLC
Other - Org Name:MEDELLA ON THE GO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:RASAVONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:725-247-6858
Mailing Address - Street 1:4760 S PECOS RD STE 103-4
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-6038
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4760 S PECOS RD STE 103-4
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-6038
Practice Address - Country:US
Practice Address - Phone:725-247-6858
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-10
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center