Provider Demographics
NPI:1215383963
Name:GARDNER, RALPH (PTA)
Entity Type:Individual
Prefix:
First Name:RALPH
Middle Name:
Last Name:GARDNER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 MILITARY TRL # 22-310
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-2869
Mailing Address - Country:US
Mailing Address - Phone:561-249-2958
Mailing Address - Fax:561-249-2976
Practice Address - Street 1:5500 MILITARY TRL # 22-310
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-2869
Practice Address - Country:US
Practice Address - Phone:561-249-2958
Practice Address - Fax:561-249-2976
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-12
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist