Provider Demographics
NPI:1447425830
Name:MUKUL KHURANA
Entity Type:Organization
Organization Name:MUKUL KHURANA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MUKUL
Authorized Official - Middle Name:
Authorized Official - Last Name:KHURANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-873-3296
Mailing Address - Street 1:780 26TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31768-6799
Mailing Address - Country:US
Mailing Address - Phone:229-873-3296
Mailing Address - Fax:229-873-3297
Practice Address - Street 1:780 26TH AVE SE
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6799
Practice Address - Country:US
Practice Address - Phone:229-873-3296
Practice Address - Fax:229-873-3297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-25
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA058975174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty