Healthcare Provider Details

I. General information

NPI: 1700741139
Provider Name (Legal Business Name): ELIJAH MALIK GILMORE PT, DPT, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2025
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16228 STATE ROAD 54
ODESSA FL
33556-3729
US

IV. Provider business mailing address

6007 EMBASSY CT
MONROE NC
28110-8071
US

V. Phone/Fax

Practice location:
  • Phone: 813-475-5599
  • Fax: 813-565-9236
Mailing address:
  • Phone: 678-709-9210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: