Healthcare Provider Details

I. General information

NPI: 1154676096
Provider Name (Legal Business Name): MEBRAHTOM TESFAI PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2012
Last Update Date: 07/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 PROFESSIONAL PARK
BECKLEY WV
25801-3624
US

IV. Provider business mailing address

1911B STRATHMORE DR
GREENSBORO NC
27410-2117
US

V. Phone/Fax

Practice location:
  • Phone: 336-394-6045
  • Fax:
Mailing address:
  • Phone: 336-394-6045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number23729
License Number StateWV

VIII. Authorized Official

Name: MEBRAHTOM WOLDU TESFAI
Title or Position: MD
Credential: MD
Phone: 336-394-6045