Provider Demographics
NPI:1548780752
Name:KILGORE, JUSTIN M (DPT)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:M
Last Name:KILGORE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 N FRONT ST STE 102
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38105-1538
Mailing Address - Country:US
Mailing Address - Phone:901-577-9484
Mailing Address - Fax:901-577-9483
Practice Address - Street 1:440 N FRONT ST STE 102
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38105-1538
Practice Address - Country:US
Practice Address - Phone:901-577-9484
Practice Address - Fax:901-577-9483
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11306225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN11306OtherTN LICENSE