=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205955549
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KHAMIS WAJDI IBRAHIM D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3081 STONE MOUNTAIN ST
-----------------------------------------------------
City | LITHONIA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30058-4426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-482-1114
-----------------------------------------------------
Fax | 770-484-1206
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3081 STONE MOUNTAIN ST
-----------------------------------------------------
City | LITHONIA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30058-4426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-482-1114
-----------------------------------------------------
Fax | 770-484-1206
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CHIR006698
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH 8106
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------