Provider Demographics
NPI:1699547489
Name:WILMORE, WILLIE EARL JR
Entity type:Individual
Prefix:
First Name:WILLIE
Middle Name:EARL
Last Name:WILMORE
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 GREEN CLOVER LN
Mailing Address - Street 2:
Mailing Address - City:ROSHARON
Mailing Address - State:TX
Mailing Address - Zip Code:77583-1556
Mailing Address - Country:US
Mailing Address - Phone:832-495-2345
Mailing Address - Fax:
Practice Address - Street 1:711 GREEN CLOVER LN
Practice Address - Street 2:
Practice Address - City:ROSHARON
Practice Address - State:TX
Practice Address - Zip Code:77583-1556
Practice Address - Country:US
Practice Address - Phone:832-495-2345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-25
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2167662225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant