=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023657541
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICHARD GARDINER PT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/01/2020
-----------------------------------------------------
Last Update Date | 01/01/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 383 S ORLEANS RD
-----------------------------------------------------
City | BREWSTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02631-2870
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-240-3500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 383 S ORLEANS RD
-----------------------------------------------------
City | BREWSTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02631-2870
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 9766
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------