Healthcare Provider Details

I. General information

NPI: 1821812801
Provider Name (Legal Business Name): GREYDON SEAN CLARK GILMORE PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2024
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2521 PIEDMONT RD NE APT 2325
ATLANTA GA
30324-6269
US

IV. Provider business mailing address

2521 PIEDMONT RD NE APT 2325
ATLANTA GA
30324-6269
US

V. Phone/Fax

Practice location:
  • Phone: 613-852-9282
  • Fax:
Mailing address:
  • Phone: 613-852-9282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: