1962511840 NPI number — MR. JONATHAN TODD GARDNER CHES, PTA, EXP

Table of content: MR. JONATHAN TODD GARDNER CHES, PTA, EXP (NPI 1962511840)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962511840 NPI number — MR. JONATHAN TODD GARDNER CHES, PTA, EXP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GARDNER
Provider First Name:
JONATHAN
Provider Middle Name:
TODD
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CHES, PTA, EXP
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:
1962511840
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:
1621 ROSELAND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KALAMAZOO
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49001-4353
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-966-1101
Provider Business Mailing Address Fax Number:
269-966-1113

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2775 W DICKMAN RD
Provider Second Line Business Practice Location Address:
SUITE L
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49015-4895
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-966-1101
Provider Business Practice Location Address Fax Number:
269-966-1113
Provider Enumeration Date:
08/30/2006

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: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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