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General NPI Number Information
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NPI Number | 1407673569
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Entity Type | Individual
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Provider Name | HAILEYESUS FENTA
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Gender | Male
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Dates
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Enumeration Date | 09/20/2024
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Last Update Date | 11/04/2024
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Provider Practice Location Address
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Address Line | 1517 AINSLIE PLACE RD
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City | INDIAN TRAIL
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State | NC
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Zip | 28079-5836
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Country | US
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Telephone | 404-246-6483
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Fax |
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Provider Business Mailing Address
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Address Line | 1517 AINSLIE PLACE RD
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City | INDIAN TRAIL
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State | NC
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Zip | 28079-5836
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Country | US
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Telephone | 404-246-6483
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 172A00000X
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Taxonomy Name | Driver
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 347C00000X
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Taxonomy Name | Private Vehicle
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License Number |
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License Number State |
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