Healthcare Provider Details

I. General information

NPI: 1770052227
Provider Name (Legal Business Name): LAUREN JO GILPIN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2018
Last Update Date: 11/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1317 N 36TH ST
SAINT JOSEPH MO
64506-2359
US

IV. Provider business mailing address

5719 S 10TH ST
SAINT JOSEPH MO
64504-1809
US

V. Phone/Fax

Practice location:
  • Phone: 816-676-1630
  • Fax:
Mailing address:
  • Phone: 816-390-6002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2007035959
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: