Provider Demographics
NPI:1508502204
Name:RED CANYON, LLC
Entity Type:Organization
Organization Name:RED CANYON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-416-7949
Mailing Address - Street 1:3501 JOHN SIMMONS ST # A203
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:MD
Mailing Address - Zip Code:21704-7964
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3501 JOHN SIMMONS ST # A203
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:MD
Practice Address - Zip Code:21704-7964
Practice Address - Country:US
Practice Address - Phone:301-882-8382
Practice Address - Fax:301-882-8399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-06
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty