Healthcare Provider Details

I. General information

NPI: 1407472111
Provider Name (Legal Business Name): SHALALEH KHOEI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2020
Last Update Date: 06/18/2020
Certification Date: 06/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15301 WARREN SHINGLE RD
BEALE AFB CA
95903-1905
US

IV. Provider business mailing address

15301 WARREN SHINGLE RD
BEALE AFB CA
95903-1905
US

V. Phone/Fax

Practice location:
  • Phone: 530-634-4756
  • Fax:
Mailing address:
  • Phone: 530-634-4756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT84068
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: