Healthcare Provider Details

I. General information

NPI: 1619495298
Provider Name (Legal Business Name): LIKUN GEBREHANA IV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2017
Last Update Date: 09/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10121 PASSARO WAY
ELK GROVE CA
95757-3421
US

IV. Provider business mailing address

10121 PASSARO WAY
ELK GROVE CA
95757
US

V. Phone/Fax

Practice location:
  • Phone: 916-793-9706
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberVN225403
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: