=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255503645
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOHAMMAD R. KHAYALI, MD A PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2008
-----------------------------------------------------
Last Update Date | 03/26/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 395 N SAN JACINTO ST STE #A
-----------------------------------------------------
City | HEMET
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92543-3109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-652-6564
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 395 N SAN JACINTO ST STE #A
-----------------------------------------------------
City | HEMET
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92543-3109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-652-6564
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MOHAMMAD R KHAYALI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 951-652-6564
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | A29943
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------