Provider Demographics
NPI:1124060082
Name:GARDNER, CORY LANE (DC)
Entity type:Individual
Prefix:MR
First Name:CORY
Middle Name:LANE
Last Name:GARDNER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 ORCHARD ST
Mailing Address - Street 2:
Mailing Address - City:ELKINS
Mailing Address - State:WV
Mailing Address - Zip Code:26241-3338
Mailing Address - Country:US
Mailing Address - Phone:304-636-2411
Mailing Address - Fax:304-636-2411
Practice Address - Street 1:301 ORCHARD ST
Practice Address - Street 2:
Practice Address - City:ELKINS
Practice Address - State:WV
Practice Address - Zip Code:26241-3338
Practice Address - Country:US
Practice Address - Phone:304-636-2411
Practice Address - Fax:304-636-2411
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV803111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV11351236OtherCIGNA
WV3810000836Medicaid
WVP00209889OtherRAILROAD MEDICARE
WVWV00803OtherTHE HEALTH PLAN
U99857Medicare UPIN
WV3810000836Medicaid