Healthcare Provider Details

I. General information

NPI: 1841641354
Provider Name (Legal Business Name): SENTAYEHU GEBREMESKEL I PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2016
Last Update Date: 06/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4709 EXPOSITION WAY
FORT WORTH TX
76244-6094
US

IV. Provider business mailing address

4709 EXPOSITION WAY
FORT WORTH TX
76244-6094
US

V. Phone/Fax

Practice location:
  • Phone: 817-798-0086
  • Fax:
Mailing address:
  • Phone: 817-798-0086
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number1119493
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: