Healthcare Provider Details

I. General information

NPI: 1093608564
Provider Name (Legal Business Name): MEHARU MATHEWOS MENEDO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2025
Last Update Date: 06/02/2025
Certification Date: 05/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2628 130TH ST SE
EVERETT WA
98208-7136
US

IV. Provider business mailing address

2628 130TH ST SE
EVERETT WA
98208-7136
US

V. Phone/Fax

Practice location:
  • Phone: 206-775-2063
  • Fax: 425-332-3501
Mailing address:
  • Phone: 206-775-2063
  • Fax: 425-332-3501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number758058
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: