Healthcare Provider Details

I. General information

NPI: 1437358975
Provider Name (Legal Business Name): CAROLYN NEOMA MOORE CTRS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

12007 S CEDAR AVE
JENKS OK
74037-3344
US

IV. Provider business mailing address

12007 S CEDAR AVE
JENKS OK
74037-3344
US

V. Phone/Fax

Practice location:
  • Phone: 918-296-0355
  • Fax:
Mailing address:
  • Phone: 918-296-0355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: