Provider Demographics
NPI:1750344206
Name:GARDNER, JERRY RYAN (DC)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:RYAN
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 1:927 COX RD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-3455
Mailing Address - Country:US
Mailing Address - Phone:704-824-4463
Mailing Address - Fax:704-824-4676
Practice Address - Street 1:927 COX RD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-3455
Practice Address - Country:US
Practice Address - Phone:704-824-4463
Practice Address - Fax:704-824-4676
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-07
Last Update Date:2010-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3039111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89085FVMedicaid
NC89085FVMedicaid
NCU88353Medicare UPIN