=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164495271
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHAUN MOORE PT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2006
-----------------------------------------------------
Last Update Date | 09/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 701 FOULK RD STE 2D
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19803-3733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-654-8142
-----------------------------------------------------
Fax | 302-478-7544
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12 PELHAM RD
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19803-4133
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-459-1851
-----------------------------------------------------
Fax | 302-654-8142
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | DE
-----------------------------------------------------