=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093523839
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GERARDUS KOLB MT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/26/2024
-----------------------------------------------------
Last Update Date | 12/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2555 S DIXIE DR STE 250
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45409-1518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-287-3721
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 407 1/2 S MAIN ST
-----------------------------------------------------
City | ENGLEWOOD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45322-1323
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-287-3721
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 33.027271
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------