MEDICARE: REINA ISABEL MOORE

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	224Z00000X	Occupational Therapy Assistant	OTA.0001494	CO

General Provider Information

NPI Number	:	1811669039
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REINA ISABEL MOORE

Provider Business Mailing Address
First Line	:	4342 KAOLIN CT
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80938-9630
Country	:	US
Telephone Number	:	931-802-3958
Fax Number	:

Provider Business Practice Location Address
First Line	:	4342 KAOLIN CT
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80938-9630
Country	:	US
Telephone Number	:	931-802-3958
Fax Number	:

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

Provider Enumeration Date	:	10/05/2021
Last Update Date	:	10/05/2021

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