Provider Demographics
NPI:1083765325
Name:GARDNER, LANCE (DC)
Entity Type:Individual
Prefix:DR
First Name:LANCE
Middle Name:
Last Name:GARDNER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6544 W THOMAS RD
Mailing Address - Street 2:SUITE 37
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85033-5738
Mailing Address - Country:US
Mailing Address - Phone:623-849-1188
Mailing Address - Fax:
Practice Address - Street 1:6544 W THOMAS RD
Practice Address - Street 2:SUITE 37
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85033-5738
Practice Address - Country:US
Practice Address - Phone:623-849-1188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7330111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0941900OtherBCBS ID NUMBER
AZZ79492Medicare ID - Type UnspecifiedID FOR MEDICARE