MEDICARE: YOHANNES FISSIHA

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	310400000X	Assisted Living Facility	AL6084	FL

General Provider Information

NPI Number	:	1295346690
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	YOHANNES FISSIHA

Provider Business Mailing Address
First Line	:	401 ORANGE AVE
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32127-4444
Country	:	US
Telephone Number	:	386-761-6268
Fax Number	:

Provider Business Practice Location Address
First Line	:	401 ORANGE AVE
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32127-4444
Country	:	US
Telephone Number	:	386-767-6268
Fax Number	:

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

Provider Enumeration Date	:	08/11/2020
Last Update Date	:	08/11/2020

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Directions to “ YOHANNES FISSIHA ” Practice Location

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