Provider Demographics
NPI:1245416551
Name:GILSON, DANE MORONI
Entity Type:Individual
Prefix:MR
First Name:DANE
Middle Name:MORONI
Last Name:GILSON
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 1:461 INCHELIUM HWY
Mailing Address - Street 2:
Mailing Address - City:KETTLE FALLS
Mailing Address - State:WA
Mailing Address - Zip Code:99141-9471
Mailing Address - Country:US
Mailing Address - Phone:509-738-9900
Mailing Address - Fax:
Practice Address - Street 1:461 INCHELIUM HWY
Practice Address - Street 2:
Practice Address - City:KETTLE FALLS
Practice Address - State:WA
Practice Address - Zip Code:99141-9471
Practice Address - Country:US
Practice Address - Phone:509-738-9900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-16
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6757287-4701172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist