Healthcare Provider Details

I. General information

NPI: 1518211408
Provider Name (Legal Business Name): CRAIG M MOORE LSA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2012
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7451 CHAPEL AVE
FORT WORTH TX
76116-7090
US

IV. Provider business mailing address

PO BOX 2626
FORT WORTH TX
76113-2626
US

V. Phone/Fax

Practice location:
  • Phone: 817-294-7444
  • Fax:
Mailing address:
  • Phone: 817-294-7444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License NumberSA00971
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: