Healthcare Provider Details

I. General information

NPI: 1386921658
Provider Name (Legal Business Name): REBECCA L. MOORE MD PROF CO LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2011
Last Update Date: 01/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 HOSPITAL LOOP
CRAIG CO
81625-8750
US

IV. Provider business mailing address

21852 E ONTARIO DR #1427
AURORA CO
80016-6048
US

V. Phone/Fax

Practice location:
  • Phone: 970-824-9411
  • Fax:
Mailing address:
  • Phone: 702-453-3799
  • Fax: 702-453-5741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number29536
License Number StateCO

VIII. Authorized Official

Name: LORI A LABRECQUE
Title or Position: ACCOUNTS MGR
Credential:
Phone: 702-453-3799