Healthcare Provider Details

I. General information

NPI: 1841660263
Provider Name (Legal Business Name): SANDOL KHALAF
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2015
Last Update Date: 09/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1821 UNIVERSITY AVE W STE 153
SAINT PAUL MN
55104-2894
US

IV. Provider business mailing address

1821 UNIVERSITY AVE W STE 153
SAINT PAUL MN
55104-2894
US

V. Phone/Fax

Practice location:
  • Phone: 612-644-0643
  • Fax:
Mailing address:
  • Phone: 612-644-0643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: