Healthcare Provider Details

I. General information

NPI: 1144676792
Provider Name (Legal Business Name): CHRISTINA MOYA M.S LAT ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2016
Last Update Date: 05/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 N COLLEGE AVE
CLARKSVILLE AR
72830-2880
US

IV. Provider business mailing address

415 N COLLEGE AVE
CLARKSVILLE AR
72830-2880
US

V. Phone/Fax

Practice location:
  • Phone: 479-979-2614
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number642
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: