Provider Demographics
NPI:1861773004
Name:KHADJENOURY LLC
Entity type:Organization
Organization Name:KHADJENOURY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:SIAMAK
Authorized Official - Middle Name:
Authorized Official - Last Name:KHADJENOURY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-833-0568
Mailing Address - Street 1:8 HAWK CIRCLE
Mailing Address - Street 2:THOREAU MIDDLE SCHOOL
Mailing Address - City:THOREAU
Mailing Address - State:NM
Mailing Address - Zip Code:84732
Mailing Address - Country:US
Mailing Address - Phone:801-833-0568
Mailing Address - Fax:
Practice Address - Street 1:8 HAWK CIRCLE
Practice Address - Street 2:EDVENTURES C/O THOREAU MIDDLE SCHOOL
Practice Address - City:THOREAU
Practice Address - State:NM
Practice Address - Zip Code:87323
Practice Address - Country:US
Practice Address - Phone:801-833-0568
Practice Address - Fax:801-930-9134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-01
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health