Provider Demographics
NPI:1861242661
Name:MAMMO, NEGEDE M
Entity type:Individual
Prefix:MR
First Name:NEGEDE
Middle Name:M
Last Name:MAMMO
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 1:1765 S 8TH ST STE 220
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80905-7910
Mailing Address - Country:US
Mailing Address - Phone:720-495-7633
Mailing Address - Fax:
Practice Address - Street 1:1765 S 8TH ST STE 220
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80905-7910
Practice Address - Country:US
Practice Address - Phone:720-495-7633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9000207681343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)