Healthcare Provider Details

I. General information

NPI: 1063135325
Provider Name (Legal Business Name): SIMON N KHOURY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2022
Last Update Date: 09/22/2022
Certification Date: 09/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3947 W HILLSDALE CT
VISALIA CA
93291-5534
US

IV. Provider business mailing address

3947 W HILLSDALE CT
VISALIA CA
93291-5534
US

V. Phone/Fax

Practice location:
  • Phone: 559-631-3966
  • Fax:
Mailing address:
  • Phone: 408-893-9656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: