MEDICARE: ABIES RACHAEL EGHAREVBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
2	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1144105099
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ABIES RACHAEL EGHAREVBA

Provider Business Mailing Address
First Line	:	1707 ACORN GLEN TRL
Second Line	:
City	:	FRESNO
State	:	TX
Zip	:	77545-2144
Country	:	US
Telephone Number	:	832-805-6419
Fax Number	:

Provider Business Practice Location Address
First Line	:	1707 ACORN GLEN TRL
Second Line	:
City	:	FRESNO
State	:	TX
Zip	:	77545-2144
Country	:	US
Telephone Number	:	832-805-6419
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/09/2025
Last Update Date	:	12/09/2025

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