Healthcare Provider Details

I. General information

NPI: 1528247814
Provider Name (Legal Business Name): SARA GARDNER LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2007
Last Update Date: 11/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 NW COLORADO AVE
BEND OR
97701-3291
US

IV. Provider business mailing address

740 NW COLORADO AVE
BEND OR
97701-3291
US

V. Phone/Fax

Practice location:
  • Phone: 541-771-7735
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number10479
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: