Healthcare Provider Details

I. General information

NPI: 1952802167
Provider Name (Legal Business Name): MR. CORY RYAN MOORE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2018
Last Update Date: 02/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13501 N BRYANT AVE
EDMOND OK
73013-6242
US

IV. Provider business mailing address

12390 AUTUMN BRK
GUTHRIE OK
73044-7593
US

V. Phone/Fax

Practice location:
  • Phone: 405-246-0222
  • Fax:
Mailing address:
  • Phone: 405-308-3426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number864
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: