MEDICARE: RYAN LEO KIEDROWSKI D.P.T.

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	225100000X	Physical Therapist	353301-2401	UT

General Provider Information

NPI Number	:	1548266166
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN LEO KIEDROWSKI D.P.T.

Provider Business Mailing Address
First Line	:	PO BOX 1875
Second Line	:
City	:	VERNAL
State	:	UT
Zip	:	84078-5875
Country	:	US
Telephone Number	:	435-789-0022
Fax Number	:

Provider Business Practice Location Address
First Line	:	1180 N VERNAL AVE
Second Line	:	STE 3
City	:	VERNAL
State	:	UT
Zip	:	84078-4819
Country	:	US
Telephone Number	:	435-789-0022
Fax Number	:

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

Provider Enumeration Date	:	06/28/2005
Last Update Date	:	07/08/2007

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