Healthcare Provider Details

I. General information

NPI: 1669095436
Provider Name (Legal Business Name): EYAYU GEBETA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2020
Last Update Date: 05/27/2020
Certification Date: 05/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 HOUSTON ST
LAVON TX
75166-1738
US

IV. Provider business mailing address

214 HOUSTON ST
LAVON TX
75166-1738
US

V. Phone/Fax

Practice location:
  • Phone: 469-556-2495
  • Fax:
Mailing address:
  • Phone: 469-556-2495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number989467
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: