1447582382 NPI number — SANDRA K GARDNER RD, LD

Table of content: SANDRA K GARDNER RD, LD (NPI 1447582382)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447582382 NPI number — SANDRA K GARDNER RD, LD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GARDNER
Provider First Name:
SANDRA
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RD, LD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BURNS
Provider Other First Name:
SANDRA
Provider Other Middle Name:
K
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1447582382
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/03/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1401 16TH ST SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILLMAR
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56201-2827
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-231-1527
Provider Business Mailing Address Fax Number:
320-231-0796

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1401 16TH ST SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILLMAR
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56201-2827
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-231-1527
Provider Business Practice Location Address Fax Number:
320-231-0796
Provider Enumeration Date:
02/03/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  1874 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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