MEDICARE: MR. MICHAEL RILEY MOORE BOC P. ABC C.F.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224P00000X	Prosthetist	OPP00120	AR
2	222Z00000X	Orthotist	OPP00120	AR

General Provider Information

NPI Number	:	1619020427
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL RILEY MOORE BOC P. ABC C.F.O.

Provider Business Mailing Address
First Line	:	615 W GROVE ST
Second Line	:
City	:	EL DORADO
State	:	AR
Zip	:	71730-4413
Country	:	US
Telephone Number	:	870-862-0241
Fax Number	:	903-838-8094

Provider Business Practice Location Address
First Line	:	615 W GROVE ST
Second Line	:
City	:	EL DORADO
State	:	AR
Zip	:	71730-4413
Country	:	US
Telephone Number	:	870-862-0241
Fax Number	:	903-838-8094

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/18/2007
Last Update Date	:	01/21/2009

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