Healthcare Provider Details

I. General information

NPI: 1437430055
Provider Name (Legal Business Name): THOMAS G MOORE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2011
Last Update Date: 11/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 MENAUL BLVD NE SUITE 26
ALBUQUERQUE NM
87107-1852
US

IV. Provider business mailing address

2510 E SUNSET RD UNIT 5-260
LAS VEGAS NV
89120-3511
US

V. Phone/Fax

Practice location:
  • Phone: 505-889-9700
  • Fax:
Mailing address:
  • Phone: 702-798-0113
  • Fax: 866-291-5242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number4981
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number4981
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: