=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720311582
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAJED M KHALIFA LSA, CST
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2009
-----------------------------------------------------
Last Update Date | 08/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1626 CALEDONIA TRL
-----------------------------------------------------
City | SUGAR LAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77479-5763
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-701-4410
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1626 CALEDONIA TRL
-----------------------------------------------------
City | SUGAR LAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77479-5763
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-701-4410
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246ZC0007X
-----------------------------------------------------
Taxonomy Name | Surgical Assistant
-----------------------------------------------------
License Number | SA00391
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------