Healthcare Provider Details

I. General information

NPI: 1003561051
Provider Name (Legal Business Name): TESFOM BERHE CCP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2022
Last Update Date: 02/17/2022
Certification Date: 02/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 MOWRY AVE
FREMONT CA
94538-1716
US

IV. Provider business mailing address

70 HARLAN ST APT 109
SAN LEANDRO CA
94577-5844
US

V. Phone/Fax

Practice location:
  • Phone: 510-797-1111
  • Fax:
Mailing address:
  • Phone: 573-465-3214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code242T00000X
TaxonomyPerfusionist
License Number149088-0159
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: