Healthcare Provider Details

I. General information

NPI: 1639066459
Provider Name (Legal Business Name): MOORE WELLNESS CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2025
Last Update Date: 06/23/2025
Certification Date: 06/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1661 WORCESTER RD STE 101
FRAMINGHAM MA
01701-5401
US

IV. Provider business mailing address

63 DEERFOOT RD
SOUTHBOROUGH MA
01772-1524
US

V. Phone/Fax

Practice location:
  • Phone: 781-254-8755
  • Fax:
Mailing address:
  • Phone: 781-254-8755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083B0002X
TaxonomyObesity Medicine (Preventive Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code163WN1003X
TaxonomyNutrition Support Registered Nurse
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL DAVID MOORE
Title or Position: PRESIDENT
Credential:
Phone: 781-254-8755