=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013468503
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES GREG MOORE PTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2016
-----------------------------------------------------
Last Update Date | 10/19/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3599 CHINABERRY LN
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34235-6640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-735-7730
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3599 CHINABERRY LN
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34235-6640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-735-7730
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | PTA24182
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------