Provider Demographics
NPI:1770067175
Name:MUSA, KHAYALA
Entity type:Individual
Prefix:
First Name:KHAYALA
Middle Name:
Last Name:MUSA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8915 OLCOTT AVE
Mailing Address - Street 2:
Mailing Address - City:MORTON GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60053-1917
Mailing Address - Country:US
Mailing Address - Phone:872-888-4199
Mailing Address - Fax:
Practice Address - Street 1:8915 OLCOTT AVE
Practice Address - Street 2:
Practice Address - City:MORTON GROVE
Practice Address - State:IL
Practice Address - Zip Code:60053-1917
Practice Address - Country:US
Practice Address - Phone:872-888-4199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL82-5449246Medicaid