Provider Demographics
NPI:1164715264
Name:GARDNER, CHRISTOPHER B (LMT)
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:B
Last Name:GARDNER
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115A FLAGLER BLVD
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-3795
Mailing Address - Country:US
Mailing Address - Phone:904-460-9444
Mailing Address - Fax:904-460-9444
Practice Address - Street 1:115A FLAGLER BLVD
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-3795
Practice Address - Country:US
Practice Address - Phone:904-460-9444
Practice Address - Fax:904-460-9444
Is Sole Proprietor?:No
Enumeration Date:2011-05-23
Last Update Date:2011-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA18195225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist