Healthcare Provider Details

I. General information

NPI: 1396871174
Provider Name (Legal Business Name): MICHAEL G MOOR CPO, LPO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 07/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25925 BARTON RD UNIT 36
LOMA LINDA CA
92354-5601
US

IV. Provider business mailing address

PO BOX 36
LOMA LINDA CA
92354-0036
US

V. Phone/Fax

Practice location:
  • Phone: 503-367-3848
  • Fax:
Mailing address:
  • Phone: 503-367-3848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberOI00000461
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberPS00000467
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: