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General NPI Number Information
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NPI Number | 1285173138
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Entity Type | Individual
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Provider Name | MATTHEW MOORE
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Gender | Male
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Dates
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Enumeration Date | 02/13/2017
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Last Update Date | 06/04/2024
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Provider Practice Location Address
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Address Line | 200 LASSO DR
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City | WARNER ROBINS
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State | GA
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Zip | 31088-6648
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Country | US
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Telephone | 478-542-4918
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Fax |
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Provider Business Mailing Address
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Address Line | 4 STONE LN APT 5341
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City | MALDEN
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State | MA
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Zip | 02148-1579
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Country | US
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Telephone | 919-889-9367
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 3774
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License Number State | MA
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