Healthcare Provider Details

I. General information

NPI: 1972147825
Provider Name (Legal Business Name): MR. BINYAM GEBREGZIABER GEBREHIWOT I
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2019
Last Update Date: 11/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4951 68TH ST
SAN DIEGO CA
92115-1704
US

IV. Provider business mailing address

4951 68TH ST
SAN DIEGO CA
92115-1704
US

V. Phone/Fax

Practice location:
  • Phone: 858-302-9839
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number105879
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: