Provider Demographics
NPI:1053714352
Name:ELKHALIFA, TARIG
Entity type:Individual
Prefix:
First Name:TARIG
Middle Name:
Last Name:ELKHALIFA
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 1:2020 E BROADWAY RD APT 131
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-1757
Mailing Address - Country:US
Mailing Address - Phone:602-373-4960
Mailing Address - Fax:
Practice Address - Street 1:2020 E BROADWAY RD APT 131
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-1757
Practice Address - Country:US
Practice Address - Phone:602-373-4960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-30
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD05323194172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ723749OtherNON-EMERGENCY MEDICAL TRANSPORTATION