Healthcare Provider Details

I. General information

NPI: 1477999449
Provider Name (Legal Business Name): LOGAN M MOORE P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2013
Last Update Date: 05/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7707 W DEER VALLEY RD STE: 100
PEORIA AZ
85382-2101
US

IV. Provider business mailing address

4715 N 32ND ST STE: 108
PHOENIX AZ
85018-3300
US

V. Phone/Fax

Practice location:
  • Phone: 623-376-9100
  • Fax: 623-376-9141
Mailing address:
  • Phone: 480-689-5520
  • Fax: 480-706-7409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number10255
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: