Provider Demographics
NPI:1225737778
Name:GODENA, KEBELE WAKO
Entity Type:Individual
Prefix:
First Name:KEBELE
Middle Name:WAKO
Last Name:GODENA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 W PAT ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57107-1839
Mailing Address - Country:US
Mailing Address - Phone:605-370-0974
Mailing Address - Fax:
Practice Address - Street 1:4201 W PAT ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57107-1839
Practice Address - Country:US
Practice Address - Phone:605-370-0974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-23
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home