Healthcare Provider Details

I. General information

NPI: 1750687281
Provider Name (Legal Business Name): ANTONIO JORGE GILMORE M.S.W/L.S.W-PENDING
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2011
Last Update Date: 02/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4285 N RANCHO DR STE 130
LAS VEGAS NV
89130-3446
US

IV. Provider business mailing address

9101 W SAHARA AVE STE 105 #190
LAS VEGAS NV
89117-5772
US

V. Phone/Fax

Practice location:
  • Phone: 702-385-5331
  • Fax: 702-385-5678
Mailing address:
  • Phone: 702-266-5636
  • Fax: 702-869-8870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: