Healthcare Provider Details

I. General information

NPI: 1700084720
Provider Name (Legal Business Name): K.F.B.H., LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2007
Last Update Date: 04/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1090 WIGWAM PKWY SUITE 100
HENDERSON NV
89074
US

IV. Provider business mailing address

1350 KELSO DUNES AVE APT. 321
HENDERSON NV
89014-7816
US

V. Phone/Fax

Practice location:
  • Phone: 702-454-0201
  • Fax:
Mailing address:
  • Phone: 702-485-6612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number11061
License Number StateNV

VIII. Authorized Official

Name: KHAIRALLAH FAYAZI
Title or Position: MANAGING MEMBER
Credential: M.D.
Phone: 602-327-5747