Provider Demographics
NPI:1730745928
Name:ETSUB NEGUSSIE HAILESELASSIE
Entity type:Organization
Organization Name:ETSUB NEGUSSIE HAILESELASSIE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ETSUB
Authorized Official - Middle Name:NEGUSSIE
Authorized Official - Last Name:HAILESELASSIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-269-7259
Mailing Address - Street 1:1702 ARBOR CREEK DR
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75040-8912
Mailing Address - Country:US
Mailing Address - Phone:469-269-7259
Mailing Address - Fax:
Practice Address - Street 1:1702 ARBOR CREEK DR
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75040-8912
Practice Address - Country:US
Practice Address - Phone:469-269-7259
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-14
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile