Provider Demographics
NPI:1750856514
Name:GEBRETSADIK, SAMUEL A
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:A
Last Name:GEBRETSADIK
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 1:476 W KEATS AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93612-2324
Mailing Address - Country:US
Mailing Address - Phone:408-638-1703
Mailing Address - Fax:
Practice Address - Street 1:476 W KEATS AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-2324
Practice Address - Country:US
Practice Address - Phone:408-638-1703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-09
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)