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NPI Code Detail

MEDICARE: JAIME RENEE GARDNER PTA

MEDICARE: JAIME RENEE 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
1225200000XPhysical Therapy Assistant08646OH
2225200000XPhysical Therapy Assistant06004856AIN

General Provider Information

NPI Number : 1902201601
Entity Type Code : Individual
Provider Name (Legal Business Name) : JAIME RENEE GARDNER PTA
Provider Business Mailing Address
First Line : 1001 ROSEMONT DR
Second Line :
City : VAN WERT
State : OH
Zip : 45891-2639
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 205 W CRAWFORD ST
Second Line :
City : VAN WERT
State : OH
Zip : 45891-1903
Country : US
Telephone Number : 418-238-1761
Fax Number : 418-238-5055
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/24/2014
Last Update Date : 10/24/2014

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