Provider Demographics
NPI:1518410828
Name:KHEYRE AND MOALIM CORPORATION
Entity Type:Organization
Organization Name:KHEYRE AND MOALIM CORPORATION
Other - Org Name:FOUNTAINHEAD CARE HOME
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SAHRA
Authorized Official - Middle Name:O
Authorized Official - Last Name:MOALIM
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER
Authorized Official - Phone:720-936-0483
Mailing Address - Street 1:1398 ZEPHYR ST
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80214-4269
Mailing Address - Country:US
Mailing Address - Phone:720-936-0483
Mailing Address - Fax:
Practice Address - Street 1:1398 ZEPHYR ST
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80214-4269
Practice Address - Country:US
Practice Address - Phone:720-936-0483
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KHEYRA & MOALLIM CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-08-03
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2304C3320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness