Provider Demographics
NPI:1487863254
Name:KHAZEN ATHLETIKARE, LLC
Entity type:Organization
Organization Name:KHAZEN ATHLETIKARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:ALLISON
Authorized Official - Last Name:KHAZEN
Authorized Official - Suffix:
Authorized Official - Credentials:MS ATC, CSCS
Authorized Official - Phone:314-368-9772
Mailing Address - Street 1:11892 WEXFORD PLACE DR
Mailing Address - Street 2:
Mailing Address - City:MARYLAND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63043-1763
Mailing Address - Country:US
Mailing Address - Phone:314-368-9772
Mailing Address - Fax:
Practice Address - Street 1:11892 WEXFORD PLACE DR
Practice Address - Street 2:
Practice Address - City:MARYLAND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63043-1763
Practice Address - Country:US
Practice Address - Phone:314-368-9772
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20001575692255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty