Provider Demographics
NPI:1245229798
Name:GARDNER, KEVIN K (PT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:K
Last Name:GARDNER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 357
Mailing Address - Street 2:28 NEW DRIFT WAY
Mailing Address - City:SCITUATE
Mailing Address - State:MA
Mailing Address - Zip Code:02066-0357
Mailing Address - Country:US
Mailing Address - Phone:781-545-8114
Mailing Address - Fax:781-545-7390
Practice Address - Street 1:28 NEW DRIFTWAY
Practice Address - Street 2:
Practice Address - City:SCITUATE
Practice Address - State:MA
Practice Address - Zip Code:02066-4532
Practice Address - Country:US
Practice Address - Phone:781-545-8114
Practice Address - Fax:781-545-7390
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5055225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY65185Medicare ID - Type Unspecified