Healthcare Provider Details

I. General information

NPI: 1033403886
Provider Name (Legal Business Name): CHRISTOPHER PAUL MOORE CPO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2011
Last Update Date: 06/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2204 IRONWOOD PL SUITE A
COEUR D ALENE ID
83814-2662
US

IV. Provider business mailing address

2204 IRONWOOD PL SUITE A
COEUR D ALENE ID
83814-2662
US

V. Phone/Fax

Practice location:
  • Phone: 208-765-0597
  • Fax: 208-765-0598
Mailing address:
  • Phone: 208-765-0597
  • Fax: 208-765-0598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberOI00000417
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberPS00000418
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: