Healthcare Provider Details

I. General information

NPI: 1750292637
Provider Name (Legal Business Name): LIEL KHALILI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1046 S ROBERTSON BLVD
LOS ANGELES CA
90035-1505
US

IV. Provider business mailing address

1046 S ROBERTSON BLVD
LOS ANGELES CA
90035-1505
US

V. Phone/Fax

Practice location:
  • Phone: 310-492-3375
  • Fax:
Mailing address:
  • Phone: 310-492-3375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: