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General NPI Number Information
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NPI Number | 1154629475
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Entity Type | Individual
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Provider Name | GABRIEL VYDRA LMT
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Gender | Male
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Dates
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Enumeration Date | 03/10/2011
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Last Update Date | 03/10/2011
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Provider Practice Location Address
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Address Line | 4891 SAWMILL RD SUITE 150
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City | COLUMBUS
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State | OH
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Zip | 43235-7266
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Country | US
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Telephone | 614-489-9855
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Fax |
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Provider Business Mailing Address
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Address Line | 4891 SAWMILL RD SUITE 150
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City | COLUMBUS
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State | OH
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Zip | 43235-7266
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Country | US
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Telephone | 614-489-9855
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 33.019464
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License Number State | OH
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