1487039657 NPI number — MR. WONDEMNEH ALEMNEH DERESSE OWNER

Table of content: MR. WONDEMNEH ALEMNEH DERESSE OWNER (NPI 1487039657)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487039657 NPI number — MR. WONDEMNEH ALEMNEH DERESSE OWNER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DERESSE
Provider First Name:
WONDEMNEH
Provider Middle Name:
ALEMNEH
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
OWNER
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DERESSE
Provider Other First Name:
WONDEMNEH
Provider Other Middle Name:
ALEMNEH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1487039657
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/29/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19142 E HAMPDEN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AURORA
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80013-5408
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
720-226-5915
Provider Business Mailing Address Fax Number:
772-264-5915

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19142 E, HAMPDEN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AURORA
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80013
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
720-226-5915
Provider Business Practice Location Address Fax Number:
772-264-5915
Provider Enumeration Date:
07/29/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 343900000X , with the licence number:  B-10018 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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