MEDICARE: MRS. COLEEN LEANN MOORE PT

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	225100000X	Physical Therapist	PT388	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5T496	OTHER		BCBS

General Provider Information

NPI Number	:	1790742021
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. COLEEN LEANN MOORE PT

Provider Business Mailing Address
First Line	:	PO BOX 841
Second Line	:
City	:	HARRISON
State	:	AR
Zip	:	72602-0841
Country	:	US
Telephone Number	:	870-743-5573
Fax Number	:	870-743-5974

Provider Business Practice Location Address
First Line	:	1801 FOREST HILLS BLVD
Second Line	:	STE 205
City	:	BELLA VISTA
State	:	AR
Zip	:	72715
Country	:	US
Telephone Number	:	479-855-9348
Fax Number	:	479-855-9358

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

Provider Enumeration Date	:	04/28/2006
Last Update Date	:	07/08/2007

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Directions to “ MRS. COLEEN LEANN MOORE PT” Practice Location

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