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General NPI Number Information
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NPI Number | 1235672791
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Entity Type | Individual
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Provider Name | TYLER GILMORE MAT, LAT, ATC
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Gender | Male
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Dates
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Enumeration Date | 11/30/2016
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Last Update Date | 05/22/2018
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Provider Practice Location Address
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Address Line | 3201 W LOOP 289 APT 127
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City | LUBBOCK
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State | TX
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Zip | 79407
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Country | US
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Telephone | 972-825-6255
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Fax |
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Provider Business Mailing Address
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Address Line | 1304 LOUISE LN
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City | ENNIS
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State | TX
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Zip | 75119-7691
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Country | US
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Telephone | 972-825-6255
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number |
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License Number State |
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