=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073325437
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ENNIS KHALEQ PT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2025
-----------------------------------------------------
Last Update Date | 01/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 64870 LA COSTA CT
-----------------------------------------------------
City | DESERT HOT SPRINGS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92240-1415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-605-3698
-----------------------------------------------------
Fax | 866-225-9947
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 69472 SERENITY RD
-----------------------------------------------------
City | CATHEDRAL CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92234-7921
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-409-6383
-----------------------------------------------------
Fax | 866-225-9947
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 303179
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------