Provider Demographics
NPI:1548815616
Name:RD PRABHU-LATA K SHETE MDS LTD
Entity type:Organization
Organization Name:RD PRABHU-LATA K SHETE MDS LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:JO
Authorized Official - Last Name:BLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-318-9072
Mailing Address - Street 1:5701 W. CHARLESTON BLVD
Mailing Address - Street 2:STE. 100
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146
Mailing Address - Country:US
Mailing Address - Phone:702-877-9514
Mailing Address - Fax:702-312-3510
Practice Address - Street 1:1905 CIVIC CENTER DRIVE
Practice Address - Street 2:STE 201
Practice Address - City:N. LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030
Practice Address - Country:US
Practice Address - Phone:702-649-3736
Practice Address - Fax:702-649-3709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-06
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic