1528063575 NPI number — GREGORY J GARDNER

Table of content: GREGORY J GARDNER (NPI 1528063575)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528063575 NPI number — GREGORY J GARDNER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GARDNER
Provider First Name:
GREGORY
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

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:
1528063575
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9350 S 150 E
Provider Second Line Business Mailing Address:
#460
Provider Business Mailing Address City Name:
SANDY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84070-2702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-255-4999
Provider Business Mailing Address Fax Number:
801-748-1865

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9350 S 150 E
Provider Second Line Business Practice Location Address:
#460
Provider Business Practice Location Address City Name:
SANDY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84070-2702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-255-4999
Provider Business Practice Location Address Fax Number:
801-748-1865
Provider Enumeration Date:
06/16/2005

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: 225100000X , with the licence number:  104149-2401 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 104149-2401 . This is a "STATE LICENSE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com