Provider Demographics
NPI:1447740717
Name:BOGALE, ADINO DEMISSIE SR
Entity Type:Individual
Prefix:
First Name:ADINO
Middle Name:DEMISSIE
Last Name:BOGALE
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1218 S CARSON WAY
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80012-4643
Mailing Address - Country:US
Mailing Address - Phone:720-206-8178
Mailing Address - Fax:720-428-8336
Practice Address - Street 1:1218 S CARSON WAY # A
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-4643
Practice Address - Country:US
Practice Address - Phone:720-206-8178
Practice Address - Fax:720-428-8336
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-12
Last Update Date:2018-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 172A00000X
CO20151668889172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO6525203OtherTHIS IS MY CREATING NUMBERS
CO$$$$$$$$$OtherTHIS IS MY ISS NUMBER