Healthcare Provider Details

I. General information

NPI: 1063029684
Provider Name (Legal Business Name): RYAN JOHN GEBO RD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2020
Last Update Date: 09/28/2020
Certification Date: 09/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 PEMBROKE AVE
ACUSHNET MA
02743-2346
US

IV. Provider business mailing address

51 PEMBROKE AVE
ACUSHNET MA
02743-2346
US

V. Phone/Fax

Practice location:
  • Phone: 774-641-4193
  • Fax:
Mailing address:
  • Phone: 774-641-4193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number3847
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: