=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245485325
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOORE THERAPEUTIC SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2008
-----------------------------------------------------
Last Update Date | 02/02/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1806 N VAN BUREN ST SUITE 110
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19802-3851
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-459-1851
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3317 TUNISON DR
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19810-3225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-459-1851
-----------------------------------------------------
Fax | 302-478-7544
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | MR. SHAUN MICHAEL MOORE
-----------------------------------------------------
Credential | P.T.
-----------------------------------------------------
Telephone | 484-459-1851
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 2003104444
-----------------------------------------------------
License Number State | DE
-----------------------------------------------------