Basic Information
| Provider Information | |||||||||
| NPI: | 1558829697 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILMORE | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | IVAN | ||||||||
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| Credential: | RBT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20014 JEWELL RD | ||||||||
| Address2: | |||||||||
| City: | BOTHELL | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980127317 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 20014 JEWELL RD | ||||||||
| Address2: | |||||||||
| City: | BOTHELL | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980127317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4259490801 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2019 | ||||||||
| LastUpdateDate: | 03/07/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP |
No ID Information.