Healthcare Provider Details

I. General information

NPI: 1164715264
Provider Name (Legal Business Name): CHRISTOPHER B GARDNER LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2011
Last Update Date: 05/23/2011
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 Code225700000X
TaxonomyMassage Therapist
License NumberMA18195
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: