MEDICARE: RICHARD KEVIN GARDNER PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	AT2236	CA

General Provider Information

NPI Number	:	1437308749
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD KEVIN GARDNER PTA

Provider Business Mailing Address
First Line	:	1932 W ACACIA AVE
Second Line	:	#23
City	:	HEMET
State	:	CA
Zip	:	92545-3786
Country	:	US
Telephone Number	:	951-760-0504
Fax Number	:

Provider Business Practice Location Address
First Line	:	44610 MONTEREY AVE
Second Line	:
City	:	PALM DESERT
State	:	CA
Zip	:	92260-3326
Country	:	US
Telephone Number	:	760-776-7720
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/10/2008
Last Update Date	:	09/10/2008

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