Healthcare Provider Details

I. General information

NPI: 1497117873
Provider Name (Legal Business Name): RACHEL MOORE PTA07659
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2016
Last Update Date: 03/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 COLEMANS XING
MARYSVILLE OH
43040-7115
US

IV. Provider business mailing address

2855 STATE ROUTE 67
BELLE CENTER OH
43310-9627
US

V. Phone/Fax

Practice location:
  • Phone: 937-578-7841
  • Fax:
Mailing address:
  • Phone: 937-935-0482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number07659
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: