MEDICARE: TESFAYE GOMALO

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	320800000X	Mental Illness Community Based Residential Treatment Facility	RTH100295	OR

General Provider Information

NPI Number	:	1255299749
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TESFAYE GOMALO

Provider Business Mailing Address
First Line	:	4436 JADE ST NE
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97305-2233
Country	:	US
Telephone Number	:	971-258-6432
Fax Number	:

Provider Business Practice Location Address
First Line	:	4436 JADE ST NE
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97305-2233
Country	:	US
Telephone Number	:	971-258-6432
Fax Number	:

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

Provider Enumeration Date	:	01/13/2026
Last Update Date	:	01/13/2026

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Directions to “ TESFAYE GOMALO ” Practice Location

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