MEDICARE: MR. TESFAYE ENDALE TRANSPORTATION

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	347E00000X	Transportation Broker	B69802540	VA

General Provider Information

NPI Number	:	1972117281
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TESFAYE ENDALE TRANSPORTATION

Provider Business Mailing Address
First Line	:	1712 EDMISTON WAY
Second Line	:
City	:	MIDLOTHIAN
State	:	VA
Zip	:	23114-3236
Country	:	US
Telephone Number	:	202-361-6175
Fax Number	:

Provider Business Practice Location Address
First Line	:	1712 EDMISTON WAY
Second Line	:
City	:	MIDLOTHIAN
State	:	VA
Zip	:	23114-3236
Country	:	US
Telephone Number	:	202-361-6175
Fax Number	:

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

Provider Enumeration Date	:	09/03/2020
Last Update Date	:	09/03/2020

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