Healthcare Provider Details

I. General information

NPI: 1457020505
Provider Name (Legal Business Name): BADREDDINE KHELIFI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2021
Last Update Date: 09/11/2021
Certification Date: 09/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2220 REVERE AVE
SAN FRANCISCO CA
94124-1924
US

IV. Provider business mailing address

2220 REVERE AVE
SAN FRANCISCO CA
94124-1924
US

V. Phone/Fax

Practice location:
  • Phone: 415-312-1322
  • Fax:
Mailing address:
  • Phone: 415-216-8168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberD1977793
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: