Provider Demographics
NPI:1376760496
Name:KHADJENOURY LLC
Entity Type:Organization
Organization Name:KHADJENOURY LLC
Other - Org Name:EDVENTURES GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SIAMAK
Authorized Official - Middle Name:
Authorized Official - Last Name:KHADJENOURY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-907-6890
Mailing Address - Street 1:8848 WILLOW HILLS CT
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84093-1889
Mailing Address - Country:US
Mailing Address - Phone:520-907-6890
Mailing Address - Fax:801-944-2940
Practice Address - Street 1:INDIAN ROUTER 7 AND HWY 191
Practice Address - Street 2:CHINLE HIGH SCHOOL
Practice Address - City:CHINLE
Practice Address - State:AZ
Practice Address - Zip Code:86503
Practice Address - Country:US
Practice Address - Phone:520-674-9570
Practice Address - Fax:520-674-9586
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health