Healthcare Provider Details

I. General information

NPI: 1578567129
Provider Name (Legal Business Name): MARC WAYNE MOORE M.P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2005
Last Update Date: 07/18/2024
Certification Date: 07/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 S POWER RD STE 123
MESA AZ
85209-6686
US

IV. Provider business mailing address

2500 S POWER RD STE 123
MESA AZ
85209-6686
US

V. Phone/Fax

Practice location:
  • Phone: 480-218-1344
  • Fax: 480-218-1356
Mailing address:
  • Phone: 480-218-1344
  • Fax: 480-218-1356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number5048
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: