Provider Demographics
NPI:1619150901
Name:KENNETH D. GILMORE,DC,PA
Entity Type:Organization
Organization Name:KENNETH D. GILMORE,DC,PA
Other - Org Name:GILMORE CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:D
Authorized Official - Last Name:GILMORE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:772-466-9575
Mailing Address - Street 1:800 VIRGINIA AVE STE 45
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34982-5893
Mailing Address - Country:US
Mailing Address - Phone:772-466-9575
Mailing Address - Fax:772-466-9475
Practice Address - Street 1:800 VIRGINIA AVE STE 45
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982-5893
Practice Address - Country:US
Practice Address - Phone:772-466-9575
Practice Address - Fax:772-466-9475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-10
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH6101111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
22467OtherBCBSFL
22467OtherBCBSFL