MEDICARE: MS. CARLITTA MICHELLE MOORE MS, LAT, ATC

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	2255A2300X	Athletic Trainer	1739	NC

General Provider Information

NPI Number	:	1861755258
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CARLITTA MICHELLE MOORE MS, LAT, ATC

Provider Business Mailing Address
First Line	:	1200 MURCHISON RD
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28301-4252
Country	:	US
Telephone Number	:	910-672-1065
Fax Number	:	910-672-1732

Provider Business Practice Location Address
First Line	:	1200 MURCHISON RD
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28301-4252
Country	:	US
Telephone Number	:	910-672-1065
Fax Number	:	910-672-1732

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

Provider Enumeration Date	:	06/20/2012
Last Update Date	:	11/21/2013

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