=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003880717
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAMMARA J MOORE DPT, OCS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/17/2006
-----------------------------------------------------
Last Update Date | 01/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 SHORELINE HWY STE 210A
-----------------------------------------------------
City | MILL VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94941-3645
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-729-0441
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 136 UPLAND RD
-----------------------------------------------------
City | KENTFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94904-2738
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-823-7154
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number | 15427
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 15427
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------