Provider Demographics
NPI:1689273294
Name:DEMBELO, DEREJE HABTE
Entity Type:Individual
Prefix:
First Name:DEREJE
Middle Name:HABTE
Last Name:DEMBELO
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 1:2765 LUMBERJACK DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-1434
Mailing Address - Country:US
Mailing Address - Phone:719-684-5638
Mailing Address - Fax:
Practice Address - Street 1:2765 LUMBERJACK DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-1434
Practice Address - Country:US
Practice Address - Phone:719-684-5638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-23
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO20201909336343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)