Provider Demographics
NPI:1912995309
Name:RD PRABHU-LATA K SHETE MDS LTD
Entity Type:Organization
Organization Name:RD PRABHU-LATA K SHETE MDS LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RACHAKONDA
Authorized Official - Middle Name:DAYANANDA
Authorized Official - Last Name:PRABHU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-877-9514
Mailing Address - Street 1:5701 W CHARLESTON BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-1217
Mailing Address - Country:US
Mailing Address - Phone:702-877-9514
Mailing Address - Fax:702-312-3510
Practice Address - Street 1:5701 W CHARLESTON BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-1217
Practice Address - Country:US
Practice Address - Phone:702-877-9514
Practice Address - Fax:702-877-0399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100506357Medicaid
CAXGG00737OtherMEDI-CAL