Healthcare Provider Details

I. General information

NPI: 1841030350
Provider Name (Legal Business Name): KHALIL LIFE SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2024
Last Update Date: 11/16/2024
Certification Date: 11/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2655 W GUADALUPE RD STE 7
MESA AZ
85202-7246
US

IV. Provider business mailing address

2655 W GUADALUPE RD STE 7
MESA AZ
85202-7246
US

V. Phone/Fax

Practice location:
  • Phone: 602-860-2354
  • Fax:
Mailing address:
  • Phone: 602-860-2354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: CERMILLIA WILLIAMS
Title or Position: CEO
Credential: MSW, MBA
Phone: 314-494-7603