Healthcare Provider Details

I. General information

NPI: 1558690487
Provider Name (Legal Business Name): PAUL PEDER GARDNER D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/24/2009
Last Update Date: 12/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5425 SOUTH SEMORAN BOULEVARD SUITE 6A
ORLANDO FL
32822-1777
US

IV. Provider business mailing address

5425 SOUTH SEMORAN BOULEVARD SUITE 6A
ORLANDO FL
32822-1777
US

V. Phone/Fax

Practice location:
  • Phone: 407-482-0052
  • Fax: 407-482-0198
Mailing address:
  • Phone: 407-482-0052
  • Fax: 407-482-0198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH9818
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: