Healthcare Provider Details

I. General information

NPI: 1346855152
Provider Name (Legal Business Name): YEVGENIY KHADZHI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2020
Last Update Date: 12/02/2021
Certification Date: 12/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4250 AUBURN BLVD
SACRAMENTO CA
95841-4100
US

IV. Provider business mailing address

4250 AUBURN BLVD
SACRAMENTO CA
95841-4100
US

V. Phone/Fax

Practice location:
  • Phone: 916-489-3336
  • Fax:
Mailing address:
  • Phone: 916-489-3336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberASW103470
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: