Healthcare Provider Details

I. General information

NPI: 1790110864
Provider Name (Legal Business Name): MR. CLAY CONRAD KHIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2013
Last Update Date: 09/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4810 E BEAVER CREEK RD
RIMROCK AZ
86335-6241
US

IV. Provider business mailing address

PO BOX 666
CLARKDALE AZ
86324-0666
US

V. Phone/Fax

Practice location:
  • Phone: 928-567-4631
  • Fax:
Mailing address:
  • Phone: 928-862-0612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSLPA8155
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: