Provider Demographics
NPI:1457580300
Name:GORE, MELISSA RAE (PTA)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:RAE
Last Name:GORE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 COMMERCE ST
Mailing Address - Street 2:
Mailing Address - City:HAWKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31036-1138
Mailing Address - Country:US
Mailing Address - Phone:478-738-4460
Mailing Address - Fax:
Practice Address - Street 1:1013 MAIN ST
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:GA
Practice Address - Zip Code:31069-3353
Practice Address - Country:US
Practice Address - Phone:478-988-8852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-13
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA002534208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation