Healthcare Provider Details

I. General information

NPI: 1760130447
Provider Name (Legal Business Name): BRYAN GARDENOUR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2022
Last Update Date: 03/12/2022
Certification Date: 03/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1535 W NASA BLVD UNIT C-1
MELBOURNE FL
32901-2614
US

IV. Provider business mailing address

300 INTERNATIONAL PKWY STE 200
LAKE MARY FL
32746-5028
US

V. Phone/Fax

Practice location:
  • Phone: 321-235-6199
  • Fax:
Mailing address:
  • Phone: 866-610-0580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: