Healthcare Provider Details

I. General information

NPI: 1003504473
Provider Name (Legal Business Name): MR. KEDUSE W FELEKE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: ASALEFEW F WOLDEGIORGISE

II. Dates (important events)

Enumeration Date: 04/25/2023
Last Update Date: 05/02/2023
Certification Date: 05/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5716 N BLACK CANYON HWY APT 48
PHOENIX AZ
85017-2110
US

IV. Provider business mailing address

5716 N BLACK CANYON HWY APT 48
PHOENIX AZ
85017-2110
US

V. Phone/Fax

Practice location:
  • Phone: 623-299-5688
  • Fax:
Mailing address:
  • Phone: 623-299-5688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: