Healthcare Provider Details

I. General information

NPI: 1669944831
Provider Name (Legal Business Name): ROSS GARDNER DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2018
Last Update Date: 01/28/2025
Certification Date: 01/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 SQUIRE POPE RD
SUMMERVILLE SC
29486-6999
US

IV. Provider business mailing address

211 SQUIRE POPE RD
SUMMERVILLE SC
29486-6999
US

V. Phone/Fax

Practice location:
  • Phone: 208-613-7361
  • Fax: 843-892-8444
Mailing address:
  • Phone: 208-613-7361
  • Fax: 843-892-8444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11763
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: