Healthcare Provider Details

I. General information

NPI: 1992623896
Provider Name (Legal Business Name): MATTIE R GILMORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2026
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11405 NOTRE DAME AVE
CLEVELAND OH
44104-2553
US

IV. Provider business mailing address

11405 NOTRE DAME AVE
CLEVELAND OH
44104-2553
US

V. Phone/Fax

Practice location:
  • Phone: 216-231-9979
  • Fax:
Mailing address:
  • Phone: 216-231-9979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number2919917
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: