Healthcare Provider Details

I. General information

NPI: 1841638863
Provider Name (Legal Business Name): GHM MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2013
Last Update Date: 06/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 W 10TH ST SUITE B
DALLAS TX
75208-4533
US

IV. Provider business mailing address

211 W 10TH ST SUITE B
DALLAS TX
75208-4533
US

V. Phone/Fax

Practice location:
  • Phone: 404-644-3410
  • Fax: 877-748-3269
Mailing address:
  • Phone:
  • Fax: 877-748-3269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number11705
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code163WP0000X
TaxonomyPain Management Registered Nurse
License NumberNO195793
License Number StateTX

VIII. Authorized Official

Name: DR. DEMITRIOUS GILMORE
Title or Position: CHIROPRACTOR
Credential: D.C.
Phone: 404-644-3410