Basic Information
| Provider Information | |||||||||
| NPI: | 1063093482 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIDANE | ||||||||
| FirstName: | TEMESGEN | ||||||||
| MiddleName: | ALEM | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1110 SHAWNEE RD | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458053529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192216715 | ||||||||
| FaxNumber: | 8666752004 | ||||||||
| Practice Location | |||||||||
| Address1: | 4125 HUNTERS PARK LN STE 116 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328377615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078550614 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2021 | ||||||||
| LastUpdateDate: | 04/16/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 30969 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.