Healthcare Provider Details

I. General information

NPI: 1609636646
Provider Name (Legal Business Name): YKEALLO HEZCHIAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2024
Last Update Date: 03/19/2024
Certification Date: 03/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 DEXTER ST
SANTA ROSA CA
95404-2438
US

IV. Provider business mailing address

625 DEXTER ST
SANTA ROSA CA
95404-2438
US

V. Phone/Fax

Practice location:
  • Phone: 707-322-8934
  • Fax:
Mailing address:
  • Phone: 707-322-8934
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License NumberD8915338
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: