Provider Demographics
NPI:1093123994
Name:KHENOUCHE, NACER (CPO)
Entity Type:Individual
Prefix:
First Name:NACER
Middle Name:
Last Name:KHENOUCHE
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4710 W 95TH ST
Mailing Address - Street 2:SUITE 11
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2546
Mailing Address - Country:US
Mailing Address - Phone:708-529-0753
Mailing Address - Fax:
Practice Address - Street 1:4710 W 95TH ST
Practice Address - Street 2:SUITE 11
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2546
Practice Address - Country:US
Practice Address - Phone:708-529-0753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-24
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213.000316222Z00000X
IL211.000279224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist