Healthcare Provider Details

I. General information

NPI: 1932213113
Provider Name (Legal Business Name): GAIL J GARDNER RD LD CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 11/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40520 COUNTY HWY 34 WHITE EARTH HEALTH CENTER
OGEMA MN
56569-9612
US

IV. Provider business mailing address

40520 COUNTY HWY 34 WHITE EARTH HEALTH CENTER
OGEMA MN
56569-9612
US

V. Phone/Fax

Practice location:
  • Phone: 218-983-4300
  • Fax: 218-983-6217
Mailing address:
  • Phone: 218-983-4300
  • Fax: 218-983-6217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1115
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number1115
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: