Provider Demographics
NPI:1740891183
Name:THEODORE, GARDY
Entity type:Individual
Prefix:
First Name:GARDY
Middle Name:
Last Name:THEODORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:546 S BROAD ST STE 2F
Mailing Address - Street 2:
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450-6601
Mailing Address - Country:US
Mailing Address - Phone:866-920-0769
Mailing Address - Fax:
Practice Address - Street 1:546 S BROAD ST STE 2F
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-6601
Practice Address - Country:US
Practice Address - Phone:866-920-0769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-10
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/Technologist