Healthcare Provider Details

I. General information

NPI: 1558957209
Provider Name (Legal Business Name): GARDNER CHIROPRACTIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2020
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2007 E QUAIL RUN RD STE 2
EMMETT ID
83617-5059
US

IV. Provider business mailing address

2007 E QUAIL RUN RD STE 2
EMMETT ID
83617-5059
US

V. Phone/Fax

Practice location:
  • Phone: 208-365-2024
  • Fax: 208-365-2046
Mailing address:
  • Phone: 208-365-2024
  • Fax: 208-365-2046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. AARON RANDALL GARDNER
Title or Position: OWNER
Credential: DC
Phone: 208-365-2024