1356596134 NPI number — DR AJAY NELLUTLA INC

Table of content: (NPI 1356596134)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356596134 NPI number — DR AJAY NELLUTLA INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR AJAY NELLUTLA INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356596134
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
FILE # 1304-1801 W.OLYMPIC BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91199-1304
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-938-0419
Provider Business Mailing Address Fax Number:
702-939-6954

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3201 S MARYLAND PKWY
Provider Second Line Business Practice Location Address:
SUITE #100
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89109-2441
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-649-8009
Provider Business Practice Location Address Fax Number:
702-649-8049
Provider Enumeration Date:
11/20/2008

Additional Information

Authorized Official

Authorized Official Last Name:
NELLUTLA
Authorized Official First Name:
AJAY
Authorized Official Middle Name:
K
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
702-649-8009

Provider Taxonomy Codes

  • Taxonomy code: 207RG0300X , with the licence number:  10766 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1356596134 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com