Healthcare Provider Details

I. General information

NPI: 1609736156
Provider Name (Legal Business Name): BRAYDEN MOORE PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2025
Last Update Date: 11/19/2025
Certification Date: 11/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 ROSEHILL DR
SOUTH BOSTON VA
24592-4843
US

IV. Provider business mailing address

2160 SWAIN RD
HALIFAX VA
24558-2278
US

V. Phone/Fax

Practice location:
  • Phone: 434-272-4201
  • Fax:
Mailing address:
  • Phone: 434-579-0197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305217331
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: