Healthcare Provider Details

I. General information

NPI: 1477054484
Provider Name (Legal Business Name): PHILLIP GORE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2018
Last Update Date: 02/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6110 POWERS AVE STE 12
JACKSONVILLE FL
32217-2256
US

IV. Provider business mailing address

6110 POWERS AVE STE 12
JACKSONVILLE FL
32217-2256
US

V. Phone/Fax

Practice location:
  • Phone: 904-859-8859
  • Fax: 904-508-0236
Mailing address:
  • Phone: 904-859-8859
  • Fax: 904-508-0236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License NumberGT600672651770
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code171R00000X
TaxonomyInterpreter
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: