Healthcare Provider Details

I. General information

NPI: 1609165877
Provider Name (Legal Business Name): DANIEL E MOORE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2011
Last Update Date: 03/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8540 SCARBOROUGH DR #200
COLORADO SPRINGS CO
80920-7502
US

IV. Provider business mailing address

715 W 26TH ST
PUEBLO CO
81003-1761
US

V. Phone/Fax

Practice location:
  • Phone: 719-630-7500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number0667
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: