Healthcare Provider Details

I. General information

NPI: 1760923775
Provider Name (Legal Business Name): THOMAS MOORE II DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2017
Last Update Date: 03/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 PASCHALL DR
DURHAM NC
27705-8534
US

IV. Provider business mailing address

5100 PASCHALL DR
DURHAM NC
27705-8534
US

V. Phone/Fax

Practice location:
  • Phone: 919-619-8208
  • Fax:
Mailing address:
  • Phone: 919-619-8208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number14932
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: