Basic Information
| Provider Information | |||||||||
| NPI: | 1598955759 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILMORE | ||||||||
| FirstName: | LONNIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1551 PROFESSIONAL LN STE 150 | ||||||||
| Address2: | |||||||||
| City: | LONGMONT | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805016972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7204944750 | ||||||||
| FaxNumber: | 7204944751 | ||||||||
| Practice Location | |||||||||
| Address1: | 1551 PROFESSIONAL LN STE 150 | ||||||||
| Address2: | |||||||||
| City: | LONGMONT | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805016972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7204944750 | ||||||||
| FaxNumber: | 7204944751 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2007 | ||||||||
| LastUpdateDate: | 03/05/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 005825 | GA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 0011034 | CO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 005825 | 01 | GA | PHYSICAL THERAPY LISENCE | OTHER | 0011034 | 01 | CO | COLORADO PHYSICAL THERAPIST | OTHER |