MEDICARE: KHADJENOURY LLC

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1942592431
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KHADJENOURY LLC

Provider Business Mailing Address
First Line	:	8848 WILLOW HILLS CT
Second Line	:
City	:	SANDY
State	:	UT
Zip	:	84093-1889
Country	:	US
Telephone Number	:	877-849-5212
Fax Number	:	801-930-9134

Provider Business Practice Location Address
First Line	:	8848 WILLOW HILLS CT
Second Line	:
City	:	SANDY
State	:	UT
Zip	:	84093-1889
Country	:	US
Telephone Number	:	877-849-5212
Fax Number	:	801-930-9134

Authorized Official
Title or Position	:	CEO
Name	:	MR. SIAMAK KHADJENOURY
Credential	:
Telephone Number	:	877-849-5212

Provider Enumeration Date	:	05/03/2011
Last Update Date	:	05/03/2011

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Directions to “KHADJENOURY LLC ” Practice Location

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