Provider Demographics
NPI:1811229917
Name:GILMORE, ACAZIA (DOM)
Entity Type:Individual
Prefix:
First Name:ACAZIA
Middle Name:
Last Name:GILMORE
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1348 PACHECO ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4222
Mailing Address - Country:US
Mailing Address - Phone:505-670-3396
Mailing Address - Fax:
Practice Address - Street 1:1348 PACHECO ST
Practice Address - Street 2:SUITE 206
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4222
Practice Address - Country:US
Practice Address - Phone:505-670-3396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-01
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM954171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist