Healthcare Provider Details

I. General information

NPI: 1629331541
Provider Name (Legal Business Name): JAMES GARDNER OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2012
Last Update Date: 12/02/2021
Certification Date: 12/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 N MEDICAL DR
SALT LAKE CITY UT
84132-0001
US

IV. Provider business mailing address

1338 S 2100 E
SALT LAKE CITY UT
84108-2244
US

V. Phone/Fax

Practice location:
  • Phone: 801-885-2129
  • Fax:
Mailing address:
  • Phone: 801-885-2129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code273Y00000X
TaxonomyRehabilitation Hospital Unit
License Number8336836-4201
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: