Provider Demographics
NPI:1750687281
Name:GILMORE, ANTONIO JORGE (MSW/LSW-PENDING)
Entity Type:Individual
Prefix:MR
First Name:ANTONIO
Middle Name:JORGE
Last Name:GILMORE
Suffix:
Gender:M
Credentials:MSW/LSW-PENDING
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:9101 W SAHARA AVE
Mailing Address - Street 2:STE 105 #190
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-5772
Mailing Address - Country:US
Mailing Address - Phone:702-266-5636
Mailing Address - Fax:702-869-8870
Practice Address - Street 1:4285 N RANCHO DR
Practice Address - Street 2:STE 130
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-3446
Practice Address - Country:US
Practice Address - Phone:702-385-5331
Practice Address - Fax:702-385-5678
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-01
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV225400000XMedicaid
NV104100000XMedicaid