MEDICARE: GEDIYON ETAFE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172A00000X	Driver	6167878	OR

General Provider Information

NPI Number	:	1952279812
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GEDIYON ETAFE

Provider Business Mailing Address
First Line	:	1725 1ST ST
Second Line	:
City	:	COLUMBIA CITY
State	:	OR
Zip	:	97018-9501
Country	:	US
Telephone Number	:	510-925-9014
Fax Number	:

Provider Business Practice Location Address
First Line	:	1725 1ST ST
Second Line	:
City	:	COLUMBIA CITY
State	:	OR
Zip	:	97018-9501
Country	:	US
Telephone Number	:	510-925-9014
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/23/2025
Last Update Date	:	10/23/2025

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Directions to “ GEDIYON ETAFE ” Practice Location

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