Healthcare Provider Details

I. General information

NPI: 1417102732
Provider Name (Legal Business Name): DEKEBO MEBRAT YADETO DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2008
Last Update Date: 01/08/2022
Certification Date: 01/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10612 SE 59TH AVE
MILWAUKIE OR
97222-2701
US

IV. Provider business mailing address

10612 SE 59TH AVE
MILWAUKIE OR
97222-2701
US

V. Phone/Fax

Practice location:
  • Phone: 503-915-3427
  • Fax: 503-342-6217
Mailing address:
  • Phone: 503-915-3427
  • Fax: 503-342-6217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3890
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code2278E1000X
TaxonomyEducational Certified Respiratory Therapist
License NumberP-898021
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number15-2418
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: