Healthcare Provider Details

I. General information

NPI: 1376145441
Provider Name (Legal Business Name): MARK GARDNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2020
Last Update Date: 11/12/2020
Certification Date: 11/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 OAK HOLLOW DR
MADISON OH
44057-3288
US

IV. Provider business mailing address

460 OAK HOLLOW DR
MADISON OH
44057-3288
US

V. Phone/Fax

Practice location:
  • Phone: 440-227-0775
  • Fax:
Mailing address:
  • Phone: 440-227-0775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: