Provider Demographics
NPI:1275714925
Name:GORE, TINA LOUISE (LMT)
Entity Type:Individual
Prefix:MS
First Name:TINA
Middle Name:LOUISE
Last Name:GORE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1170 COLORADO DR
Mailing Address - Street 2:
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75167-8199
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:972-938-8780
Practice Address - Street 1:1170 COLORADO DR
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75167-8199
Practice Address - Country:US
Practice Address - Phone:972-938-2316
Practice Address - Fax:972-937-8780
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-23
Last Update Date:2007-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT104092171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor