Healthcare Provider Details

I. General information

NPI: 1578533790
Provider Name (Legal Business Name): JEFFREY GLENN MOORE ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ROOM 118 FIELDHOUSE ALL AMERICAN DRIVE
UNIVERSITY MS
38677
US

IV. Provider business mailing address

181 HIGHWAY 334
OXFORD MS
38655-9402
US

V. Phone/Fax

Practice location:
  • Phone: 662-915-7536
  • Fax:
Mailing address:
  • Phone: 662-281-8314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0087
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: