Provider Demographics
NPI:1629206172
Name:GILMORE, KEELEY OMEGA
Entity type:Individual
Prefix:MS
First Name:KEELEY
Middle Name:OMEGA
Last Name:GILMORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KEELY
Other - Middle Name:
Other - Last Name:GILMORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:P O BOX 92262
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90809
Mailing Address - Country:US
Mailing Address - Phone:562-338-0169
Mailing Address - Fax:
Practice Address - Street 1:510 S VERMONT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-1912
Practice Address - Country:US
Practice Address - Phone:213-947-6914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-23
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker