MEDICARE: DR. ANTOINE G KHOURY DC

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	111N00000X	Chiropractor	DC13576	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DC0135760	OTHER	CA	BLUE SHIELD OF CALIFORNIA
2	54126	OTHER	CA	ASHP

General Provider Information

NPI Number	:	1003985680
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANTOINE G KHOURY DC

Provider Business Mailing Address
First Line	:	1211 N VERMONT AVE STE 100
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90029-1748
Country	:	US
Telephone Number	:	323-663-0259
Fax Number	:	323-663-0297

Provider Business Practice Location Address
First Line	:	1211 N VERMONT AVE STE 100
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90029-1748
Country	:	US
Telephone Number	:	323-663-0259
Fax Number	:	323-663-0297

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/07/2006
Last Update Date	:	07/08/2007

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