Provider Demographics
NPI:1851583892
Name:HABTE, TEKLE TEKIE (LVN)
Entity Type:Individual
Prefix:MR
First Name:TEKLE
Middle Name:TEKIE
Last Name:HABTE
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:MR
Other - First Name:TEKLE
Other - Middle Name:HABTE
Other - Last Name:TEKIE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LVN
Mailing Address - Street 1:1969 VALENZUELA CT
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-8657
Mailing Address - Country:US
Mailing Address - Phone:209-679-3635
Mailing Address - Fax:
Practice Address - Street 1:1124 INTERNATIONAL BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94606
Practice Address - Country:US
Practice Address - Phone:510-533-0800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-14
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 147125164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAVN147125Medicare Oscar/Certification