Provider Demographics
NPI:1861190530
Name:GEBRESELASSE, HABTOM T
Entity type:Individual
Prefix:
First Name:HABTOM
Middle Name:T
Last Name:GEBRESELASSE
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 1:9815 E ALABAMA DR APT 411
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80247-6335
Mailing Address - Country:US
Mailing Address - Phone:720-416-9787
Mailing Address - Fax:
Practice Address - Street 1:9815 E ALABAMA DR APT 411
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80247-6335
Practice Address - Country:US
Practice Address - Phone:720-416-9787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-21
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO873655499Other873655499