Provider Demographics
NPI:1336146604
Name:GARDNER, RICHARD M (DC)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:M
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 1:324 HOHUM DR.
Mailing Address - Street 2:
Mailing Address - City:BRINKHAVEN
Mailing Address - State:OH
Mailing Address - Zip Code:43006
Mailing Address - Country:US
Mailing Address - Phone:740-599-6197
Mailing Address - Fax:419-994-5552
Practice Address - Street 1:2863 COUNTY ROAD 529
Practice Address - Street 2:
Practice Address - City:LOUDONVILLE
Practice Address - State:OH
Practice Address - Zip Code:44842-9202
Practice Address - Country:US
Practice Address - Phone:419-994-5551
Practice Address - Fax:419-994-5552
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH713111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0603029Medicaid
OHGA0452833Medicare ID - Type Unspecified
OHT46969Medicare UPIN