Provider Demographics
NPI:1396596813
Name:GARDNER, GAVIN DAVID (DC)
Entity type:Individual
Prefix:DR
First Name:GAVIN
Middle Name:DAVID
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 1:19599 CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLE POINT
Mailing Address - State:OH
Mailing Address - Zip Code:45863-9618
Mailing Address - Country:US
Mailing Address - Phone:419-605-6283
Mailing Address - Fax:
Practice Address - Street 1:10963 VAN WERT DECATUR RD
Practice Address - Street 2:
Practice Address - City:VAN WERT
Practice Address - State:OH
Practice Address - Zip Code:45891-9211
Practice Address - Country:US
Practice Address - Phone:419-238-6686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-01
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHDC-05344111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor