=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033603576
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MORGAN MOORE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2018
-----------------------------------------------------
Last Update Date | 06/19/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 156 S JACKSON AVE
-----------------------------------------------------
City | AZUSA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91702-4254
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-662-6297
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 156 S JACKSON AVE
-----------------------------------------------------
City | AZUSA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91702-4254
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-662-6297
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------