Healthcare Provider Details

I. General information

NPI: 1407150519
Provider Name (Legal Business Name): HEIDI MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2011
Last Update Date: 10/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7710 OLENTANGY RIVER RD STE 100
COLUMBUS OH
43235-1353
US

IV. Provider business mailing address

3869 RIMROCK AVE
GROVE CITY OH
43123-8480
US

V. Phone/Fax

Practice location:
  • Phone: 614-841-3900
  • Fax:
Mailing address:
  • Phone: 614-330-4183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number07085
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: