Healthcare Provider Details

I. General information

NPI: 1336364124
Provider Name (Legal Business Name): KEITH J GARDNER A.T.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 10/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 E COLLEGE BLVD
ROSWELL NM
88201-5158
US

IV. Provider business mailing address

113 E COLLEGE BLVD
ROSWELL NM
88201-5158
US

V. Phone/Fax

Practice location:
  • Phone: 575-622-6500
  • Fax: 575-622-9777
Mailing address:
  • Phone: 575-622-6500
  • Fax: 575-622-9777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number72
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: