1285963413 NPI number — DR. GARDNER OUTPATIENT PROGRAM

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285963413 NPI number — DR. GARDNER OUTPATIENT PROGRAM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR. GARDNER OUTPATIENT PROGRAM
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285963413
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/17/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 1978
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUCERNE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95458
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-274-9299
Provider Business Mailing Address Fax Number:
707-274-9297

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6300 E. HWY 20
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUCERNE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95458
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-274-9299
Provider Business Practice Location Address Fax Number:
707-274-9297
Provider Enumeration Date:
12/17/2009

Additional Information

Authorized Official

Authorized Official Last Name:
LANIER
Authorized Official First Name:
KAY
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
707-274-9299

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  170007AP , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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