Healthcare Provider Details

I. General information

NPI: 1346080462
Provider Name (Legal Business Name): BRYANT LEE GARDNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2024
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

329 LEMMON LN
RIGBY ID
83442-4921
US

IV. Provider business mailing address

329 LEMMON LN
RIGBY ID
83442-4921
US

V. Phone/Fax

Practice location:
  • Phone: 208-227-5182
  • Fax: 208-252-7535
Mailing address:
  • Phone: 208-227-3254
  • Fax: 208-252-7535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-9083
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: