Healthcare Provider Details

I. General information

NPI: 1467828582
Provider Name (Legal Business Name): MOHAMED BENKHADRA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2015
Last Update Date: 12/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12412 MONROE AVE
GRANDVIEW MO
64030-1529
US

IV. Provider business mailing address

1101 HAMPTON DR.
RAYMORE MO
64083-4010
US

V. Phone/Fax

Practice location:
  • Phone: 913-206-3476
  • Fax:
Mailing address:
  • Phone: 913-206-3476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code344600000X
TaxonomyTaxi
License Number2015/01
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: