Provider Demographics
NPI:1619005311
Name:THE GARDNER CLINIC OF CHIROPRACTIC
Entity Type:Organization
Organization Name:THE GARDNER CLINIC OF CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:727-577-0988
Mailing Address - Street 1:418 94TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-2522
Mailing Address - Country:US
Mailing Address - Phone:727-577-0988
Mailing Address - Fax:727-576-7994
Practice Address - Street 1:418 94TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-2522
Practice Address - Country:US
Practice Address - Phone:727-577-0988
Practice Address - Fax:727-576-7994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH3635111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL88907Medicare ID - Type Unspecified