Provider Demographics
NPI:1811368806
Name:GARDNER, HOLIS
Entity Type:Individual
Prefix:
First Name:HOLIS
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31764 CASINO DR
Mailing Address - Street 2:STE 300
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-4571
Mailing Address - Country:US
Mailing Address - Phone:951-471-4645
Mailing Address - Fax:951-471-4687
Practice Address - Street 1:31764 CASINO DR
Practice Address - Street 2:STE 300
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-4571
Practice Address - Country:US
Practice Address - Phone:951-471-4645
Practice Address - Fax:951-471-4687
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-15
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA260944164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse