Provider Demographics
NPI:1467105502
Name:HAILU, EYOUEL
Entity Type:Individual
Prefix:
First Name:EYOUEL
Middle Name:
Last Name:HAILU
Suffix:
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 1:2901 S SEPULVEDA BLVD APT 366
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-3993
Mailing Address - Country:US
Mailing Address - Phone:818-602-8571
Mailing Address - Fax:
Practice Address - Street 1:2901 S SEPULVEDA BLVD APT 366
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-3993
Practice Address - Country:US
Practice Address - Phone:818-602-8571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-29
Last Update Date:2022-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21428225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist