=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407669419
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIMOTHY JAMES GARDING
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2025
-----------------------------------------------------
Last Update Date | 01/31/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4801 VETERANS DR
-----------------------------------------------------
City | SAINT CLOUD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56303-2015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-252-1670
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1285 15TH ST NE APT 204
-----------------------------------------------------
City | SAUK RAPIDS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56379-2596
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-330-3589
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 824692
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------