Healthcare Provider Details

I. General information

NPI: 1740783315
Provider Name (Legal Business Name): SERKALEM LEYIKUN MULUGETA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2018
Last Update Date: 03/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1999 HARRISON ST
OAKLAND CA
94612-3520
US

IV. Provider business mailing address

4127 REDWOOD RD
OAKLAND CA
94619-2329
US

V. Phone/Fax

Practice location:
  • Phone: 916-597-7166
  • Fax:
Mailing address:
  • Phone: 510-703-2353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: