=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093520439
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GENE WILLARD LYBARGER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2025
-----------------------------------------------------
Last Update Date | 02/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1451 GAMBIER RD
-----------------------------------------------------
City | MOUNT VERNON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43050-9112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-397-1607
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 495 RIDGELAND DR
-----------------------------------------------------
City | HOWARD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43028-9489
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-504-0456
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 09988
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------