Provider Demographics
NPI:1518757418
Name:MENGISTU, DAGIM A (PROVIDER)
Entity type:Individual
Prefix:
First Name:DAGIM
Middle Name:A
Last Name:MENGISTU
Suffix:
Gender:M
Credentials:PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2309 74TH ST SE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98203-5453
Mailing Address - Country:US
Mailing Address - Phone:206-898-1028
Mailing Address - Fax:425-967-5850
Practice Address - Street 1:2309 74TH ST SE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203-5453
Practice Address - Country:US
Practice Address - Phone:206-898-1028
Practice Address - Fax:206-898-1028
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-12
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home