Provider Demographics
NPI:1508397076
Name:GILMORE, KELVIN (FACT I RAS)
Entity Type:Individual
Prefix:
First Name:KELVIN
Middle Name:
Last Name:GILMORE
Suffix:
Gender:M
Credentials:FACT I RAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4851 S DARLINGTON AVE APT 6C
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-7247
Mailing Address - Country:US
Mailing Address - Phone:918-378-0538
Mailing Address - Fax:
Practice Address - Street 1:4851 S DARLINGTON AVE APT 6C
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-7247
Practice Address - Country:US
Practice Address - Phone:918-378-0538
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-25
Last Update Date:2017-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)