Provider Demographics
NPI:1235672791
Name:GILMORE, TYLER (MAT, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:GILMORE
Suffix:
Gender:M
Credentials:MAT, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 LOUISE LN
Mailing Address - Street 2:
Mailing Address - City:ENNIS
Mailing Address - State:TX
Mailing Address - Zip Code:75119-7691
Mailing Address - Country:US
Mailing Address - Phone:972-825-6255
Mailing Address - Fax:
Practice Address - Street 1:3201 W LOOP 289
Practice Address - Street 2:APT 127
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79407
Practice Address - Country:US
Practice Address - Phone:972-825-6255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-30
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program