1619046836 NPI number — DR. LEORA GARDNER,PH.D.,P.A.

Table of content: (NPI 1619046836)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619046836 NPI number — DR. LEORA GARDNER,PH.D.,P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR. LEORA GARDNER,PH.D.,P.A.
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:
1619046836
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2600 N MILITARY TRL
Provider Second Line Business Mailing Address:
SUITE 270
Provider Business Mailing Address City Name:
BOCA RATON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33431-6312
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-414-1650
Provider Business Mailing Address Fax Number:
561-241-4943

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2600 N MILITARY TRL
Provider Second Line Business Practice Location Address:
SUITE 270
Provider Business Practice Location Address City Name:
BOCA RATON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33431-6312
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-414-1650
Provider Business Practice Location Address Fax Number:
561-241-4943
Provider Enumeration Date:
11/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GARDNER
Authorized Official First Name:
LEORA
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
561-414-1650

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PY0005116 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PY0005116 . This is a "LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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