Provider Demographics
NPI:1841547593
Name:FAMILY MEDICAL CLINIC & LASER SKIN SOLUTIONS
Entity type:Organization
Organization Name:FAMILY MEDICAL CLINIC & LASER SKIN SOLUTIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CNP
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:CNP
Authorized Official - Phone:740-323-3427
Mailing Address - Street 1:8781 SOMERSET RD
Mailing Address - Street 2:
Mailing Address - City:THORNVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43076-9390
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:905 N 21ST ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-7251
Practice Address - Country:US
Practice Address - Phone:740-323-3427
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-13
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN222488-COA1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty