Provider Demographics
NPI:1629723911
Name:REDAE, ROBEL BEDALI
Entity Type:Individual
Prefix:
First Name:ROBEL
Middle Name:BEDALI
Last Name:REDAE
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 1:2703 W 26TH STREET RD
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-8022
Mailing Address - Country:US
Mailing Address - Phone:206-476-5495
Mailing Address - Fax:
Practice Address - Street 1:2703 W 26TH STREET RD
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-8022
Practice Address - Country:US
Practice Address - Phone:206-476-5495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-16
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO12-257-0510172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver