Provider Demographics
NPI:1083629810
Name:GARDNER CHIROPRACTIC CLINIC, P.A.
Entity Type:Organization
Organization Name:GARDNER CHIROPRACTIC CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:L
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:501-329-2700
Mailing Address - Street 1:813 OAK STREET
Mailing Address - Street 2:SUITE 7
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72032-4400
Mailing Address - Country:US
Mailing Address - Phone:501-329-2700
Mailing Address - Fax:501-329-5282
Practice Address - Street 1:813 OAK STREET
Practice Address - Street 2:SUITE 7
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-4400
Practice Address - Country:US
Practice Address - Phone:501-329-2700
Practice Address - Fax:501-329-5282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1231111N00000X
CO4618111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARU21275Medicare UPIN
AR5C638Medicare ID - Type Unspecified