Healthcare Provider Details

I. General information

NPI: 1811597024
Provider Name (Legal Business Name): ANTHONY KEBEDE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2020
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1780 E US HIGHWAY 40
GREENCASTLE IN
46135-8722
US

IV. Provider business mailing address

2924 HARRISON AVE
TERRE HAUTE IN
47803-3731
US

V. Phone/Fax

Practice location:
  • Phone: 260-437-5834
  • Fax:
Mailing address:
  • Phone: 260-437-5834
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2000015372
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: