Healthcare Provider Details

I. General information

NPI: 1255947784
Provider Name (Legal Business Name): ERIC MOORE OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2020
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 WEBSTER AVE
RONKONKOMA NY
11779-1626
US

IV. Provider business mailing address

50 WEBSTER AVE
RONKONKOMA NY
11779-1626
US

V. Phone/Fax

Practice location:
  • Phone: 585-545-0229
  • Fax:
Mailing address:
  • Phone: 585-545-0229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number025006
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: