Provider Demographics
NPI:1396199675
Name:GILMOUR, WAYNE JAMES
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:JAMES
Last Name:GILMOUR
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 1:19510 VENTURA BLVD
Mailing Address - Street 2:STE 106
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-2974
Mailing Address - Country:US
Mailing Address - Phone:661-254-0077
Mailing Address - Fax:
Practice Address - Street 1:10725 ZELZAH AVE
Practice Address - Street 2:STE B
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344-4431
Practice Address - Country:US
Practice Address - Phone:818-832-8383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-22
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA291304225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist