Healthcare Provider Details

I. General information

NPI: 1417960113
Provider Name (Legal Business Name): TRESA CAROL MOORE L.M.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 GAVILAN CANYON ROAD
RUIDOSO NM
88345
US

IV. Provider business mailing address

PO BOX 7191
RUIDOSO NM
88355-7191
US

V. Phone/Fax

Practice location:
  • Phone: 505-937-0518
  • Fax:
Mailing address:
  • Phone: 505-937-0518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number3292
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: