Healthcare Provider Details

I. General information

NPI: 1336981141
Provider Name (Legal Business Name): KIDUS DEGU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2024
Last Update Date: 08/05/2025
Certification Date: 08/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1260 MORENA BLVD STE 100
SAN DIEGO CA
92110-3850
US

IV. Provider business mailing address

1260 MORENA BLVD STE 100
SAN DIEGO CA
92110-3850
US

V. Phone/Fax

Practice location:
  • Phone: 619-398-0355
  • Fax:
Mailing address:
  • Phone: 619-398-0355
  • Fax: 619-398-0355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: