Provider Demographics
NPI:1821036856
Name:GARDNER, JAMES CRIDDLE (DC)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:CRIDDLE
Last Name:GARDNER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4317 AMBER LN
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-4640
Mailing Address - Country:US
Mailing Address - Phone:208-529-1919
Mailing Address - Fax:208-552-9447
Practice Address - Street 1:1220 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6147
Practice Address - Country:US
Practice Address - Phone:208-529-1919
Practice Address - Fax:208-552-9447
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-904111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U78857Medicare UPIN