Provider Demographics
NPI:1720120900
Name:GARDNER, JOHN KEVIN (CP)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:KEVIN
Last Name:GARDNER
Suffix:
Gender:M
Credentials:CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:979 E 3RD ST STE 300
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37403-2187
Mailing Address - Country:US
Mailing Address - Phone:423-757-0792
Mailing Address - Fax:423-757-0770
Practice Address - Street 1:2108 E 3RD ST STE 100
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-2623
Practice Address - Country:US
Practice Address - Phone:423-493-2395
Practice Address - Fax:423-493-2368
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPRO94224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
6326170001Medicare PIN
TN1455062Medicaid