Healthcare Provider Details

I. General information

NPI: 1578606612
Provider Name (Legal Business Name): MARGUERITE THERESA MOORE PH.D, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 02/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 PRESQUE ISLE, NORTHERN MICHIGAN UNIVERSITY SCHOOL OF HEALTH AND HUMAN PERFORMANCE, PEIF BUILDING
MARQUETTE MI
49855-2634
US

IV. Provider business mailing address

47 WHITE OAK DR
MARQUETTE MI
49855-9450
US

V. Phone/Fax

Practice location:
  • Phone: 906-227-2239
  • Fax: 906-227-2181
Mailing address:
  • Phone: 906-226-4549
  • Fax: 906-227-2181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: