MEDICARE: KHALIL FOUNDATION

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	106H00000X	Marriage & Family Therapist	77379	CA
2	2084P0800X	Psychiatry Physician	A115077	CA

General Provider Information

NPI Number	:	1407225709
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KHALIL FOUNDATION

Provider Business Mailing Address
First Line	:	999 N MAIN ST
Second Line	:	SUITE 103
City	:	GLEN ELLYN
State	:	IL
Zip	:	60137-3581
Country	:	US
Telephone Number	:	630-474-4414
Fax Number	:	630-230-3364

Provider Business Practice Location Address
First Line	:	3033 SCOTT BLVD
Second Line	:
City	:	SANTA CLARA
State	:	CA
Zip	:	95054-3316
Country	:	US
Telephone Number	:	630-474-4414
Fax Number	:	630-230-3364

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	HOOMAN KESHAVARZI
Credential	:
Telephone Number	:	224-622-3116

Provider Enumeration Date	:	09/17/2015
Last Update Date	:	10/07/2015

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Directions to “KHALIL FOUNDATION ” Practice Location

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