Healthcare Provider Details

I. General information

NPI: 1750272142
Provider Name (Legal Business Name): LETRICE NICOLE GILMORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2025
Last Update Date: 07/14/2025
Certification Date: 07/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24117 N MOJAVE LN
FLORENCE AZ
85132-5209
US

IV. Provider business mailing address

24117 N MOJAVE LN
FLORENCE AZ
85132-5209
US

V. Phone/Fax

Practice location:
  • Phone: 520-518-1757
  • Fax:
Mailing address:
  • Phone: 520-518-1757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: