MEDICARE: EZEKIEL KIMURGOR RUTO

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	164W00000X	Licensed Practical Nurse	PN.126891-M-IV	OH
2	163WH0200X	Home Health Registered Nurse	423804	OH

General Provider Information

NPI Number	:	1639425853
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EZEKIEL KIMURGOR RUTO

Provider Business Mailing Address
First Line	:	872 TAPESTRY PARK DR APT 101
Second Line	:
City	:	LEWIS CENTER
State	:	OH
Zip	:	43035-7849
Country	:	US
Telephone Number	:	614-256-2543
Fax Number	:

Provider Business Practice Location Address
First Line	:	2700 E DUBLIN GRANVILLE RD STE 590
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43231-4094
Country	:	US
Telephone Number	:	614-256-2543
Fax Number	:

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

Provider Enumeration Date	:	07/25/2012
Last Update Date	:	04/20/2021

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