Healthcare Provider Details

I. General information

NPI: 1811639321
Provider Name (Legal Business Name): MICHAEL JOSEPH MOORE LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2022
Last Update Date: 04/13/2022
Certification Date: 04/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 RIDGEDALE AVE
MADISON NJ
07940-1295
US

IV. Provider business mailing address

1001 WHISPERING WAY APT 193
ABERDEEN NJ
07747-1983
US

V. Phone/Fax

Practice location:
  • Phone: 973-593-3117
  • Fax:
Mailing address:
  • Phone: 201-741-8270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number25MT00285700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: