Provider Demographics
NPI:1306507603
Name:SOUL TO SOUL IHCA
Entity type:Organization
Organization Name:SOUL TO SOUL IHCA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DEKEBO
Authorized Official - Middle Name:M
Authorized Official - Last Name:YADETO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-915-3427
Mailing Address - Street 1:10612 SE 59TH AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-2701
Mailing Address - Country:US
Mailing Address - Phone:503-342-6141
Mailing Address - Fax:503-342-6217
Practice Address - Street 1:10612 SE 59TH AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-2701
Practice Address - Country:US
Practice Address - Phone:503-342-6141
Practice Address - Fax:503-342-6217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-07
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1Medicaid