MEDICARE: KEBELE WAKO GODENA

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	311ZA0620X	Adult Care Home Facility

General Provider Information

NPI Number	:	1225737778
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEBELE WAKO GODENA

Provider Business Mailing Address
First Line	:	4201 W PAT ST
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57107-1839
Country	:	US
Telephone Number	:	605-370-0974
Fax Number	:

Provider Business Practice Location Address
First Line	:	4201 W PAT ST
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57107-1839
Country	:	US
Telephone Number	:	605-370-0974
Fax Number	:

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

Provider Enumeration Date	:	02/23/2023
Last Update Date	:	02/23/2023

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Directions to “ KEBELE WAKO GODENA ” Practice Location

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