Provider Demographics
NPI:1184909889
Name:KHAIS, ROMAN
Entity type:Individual
Prefix:
First Name:ROMAN
Middle Name:
Last Name:KHAIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10284 CORTE FINA LN
Mailing Address - Street 2:
Mailing Address - City:BELLFLOWER
Mailing Address - State:CA
Mailing Address - Zip Code:90706-1071
Mailing Address - Country:US
Mailing Address - Phone:562-310-9747
Mailing Address - Fax:
Practice Address - Street 1:10284 CORTE FINA LN
Practice Address - Street 2:
Practice Address - City:BELLFLOWER
Practice Address - State:CA
Practice Address - Zip Code:90706-1071
Practice Address - Country:US
Practice Address - Phone:562-310-9747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-13
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4903112471C3402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography