Provider Demographics
NPI:1598955759
Name:GILMORE, LONNIE (PT)
Entity Type:Individual
Prefix:
First Name:LONNIE
Middle Name:
Last Name:GILMORE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1551 PROFESSIONAL LN STE 150
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-6972
Mailing Address - Country:US
Mailing Address - Phone:720-494-4750
Mailing Address - Fax:720-494-4751
Practice Address - Street 1:1551 PROFESSIONAL LN STE 150
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-6972
Practice Address - Country:US
Practice Address - Phone:720-494-4750
Practice Address - Fax:720-494-4751
Is Sole Proprietor?:No
Enumeration Date:2007-07-25
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005825225100000X
CO0011034225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA005825OtherPHYSICAL THERAPY LISENCE
CO0011034OtherCOLORADO PHYSICAL THERAPIST