Healthcare Provider Details

I. General information

NPI: 1528382728
Provider Name (Legal Business Name): ADAM WAYNE MOORE LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2010
Last Update Date: 03/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5949 W RAYMOND ST
INDIANAPOLIS IN
46241-4348
US

IV. Provider business mailing address

13249 KOMATITE WAY UNIT 500
FISHERS IN
46038-5441
US

V. Phone/Fax

Practice location:
  • Phone: 317-247-1579
  • Fax:
Mailing address:
  • Phone: 812-236-5250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36001519A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: