Provider Demographics
NPI:1902041387
Name:KHALILI, JACK J (DC)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:J
Last Name:KHALILI
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10650 HOLMAN AVE
Mailing Address - Street 2:106
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-5961
Mailing Address - Country:US
Mailing Address - Phone:310-666-4044
Mailing Address - Fax:
Practice Address - Street 1:10650 HOLMAN AVE
Practice Address - Street 2:106
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-5961
Practice Address - Country:US
Practice Address - Phone:310-666-4044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-12
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26751111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor