Healthcare Provider Details

I. General information

NPI: 1912009986
Provider Name (Legal Business Name): JOSEPHINE DILLARD GARDNER R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 FREEDOM WAY
AUGUSTA GA
30904-6258
US

IV. Provider business mailing address

2755 HAZEL ST
AUGUSTA GA
30909-5202
US

V. Phone/Fax

Practice location:
  • Phone: 706-733-0188
  • Fax: 706-481-6734
Mailing address:
  • Phone: 706-733-0188
  • Fax: 706-481-6734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: