Provider Demographics
NPI:1871619437
Name:GILMORE, JALEEL AZIM
Entity type:Individual
Prefix:
First Name:JALEEL
Middle Name:AZIM
Last Name:GILMORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:879 W 190TH ST STE 400-56
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248-4220
Mailing Address - Country:US
Mailing Address - Phone:323-702-6890
Mailing Address - Fax:
Practice Address - Street 1:879 W 190TH ST STE 400-56
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-4220
Practice Address - Country:US
Practice Address - Phone:323-702-6890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56751172M00000X
225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No172M00000XOther Service ProvidersMechanotherapist