Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111N00000X | Chiropractor | CH6106 | FL |
N | 111NN1001X | Nutrition | CH6106 | FL |
N | 111NR0200X | Radiology | CH6106 | FL |
N | 213ER0200X | Radiology | CH6106 | FL |
N | 111NR0400X | Rehabilitation Chiropractor | CH6106 | FL |
Y | 111NS0005X | Chiropractic Sports Physician | CH6106 | FL |
N | 111NX0100X | Occupational Health | CH6106 | FL |
NPI | 1962589309 |
---|---|
Provider Name | Dr. Kenneth David Gilmore |
First Address | Fort Pierce, FL 34982-5893 |
Second Address | Fort Pierce, FL 34982-5893 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/11/2006 |
Last Update Date | 10/12/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
22467 | BCBS FL (01) | FL |
4601271 | AETNA PROVIDER ID (01) | FL |
U12714 | (02) | FL |