Provider Demographics
NPI:1548076383
Name:GARDNER, BRANDON ROYCE
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:ROYCE
Last Name:GARDNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32405 DIAGONAL RD
Mailing Address - Street 2:
Mailing Address - City:HERMISTON
Mailing Address - State:OR
Mailing Address - Zip Code:97838-7503
Mailing Address - Country:US
Mailing Address - Phone:541-567-2593
Mailing Address - Fax:
Practice Address - Street 1:32405 DIAGONAL RD
Practice Address - Street 2:
Practice Address - City:HERMISTON
Practice Address - State:OR
Practice Address - Zip Code:97838-7503
Practice Address - Country:US
Practice Address - Phone:541-567-2593
Practice Address - Fax:888-977-2106
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-06
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility