Healthcare Provider Details

I. General information

NPI: 1093008146
Provider Name (Legal Business Name): GARDNERS MASSAGE THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2011
Last Update Date: 05/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115A FLAGLER BLVD
ST AUGUSTINE FL
32080-3795
US

IV. Provider business mailing address

115A FLAGLER BLVD
ST AUGUSTINE FL
32080-3795
US

V. Phone/Fax

Practice location:
  • Phone: 904-460-9444
  • Fax: 904-460-9444
Mailing address:
  • Phone: 904-460-9444
  • Fax: 904-460-9444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMM20376
License Number StateFL

VIII. Authorized Official

Name: MR. CHRISTOPHER B GARDNER
Title or Position: PRESIDENT / OWNER
Credential: LMT
Phone: 904-460-9444