=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306329255
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT R MOAURO JR. PT, DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2018
-----------------------------------------------------
Last Update Date | 11/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 GATEWAY DR STE 300
-----------------------------------------------------
City | BEAVER DAM
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53916-9176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-974-4378
-----------------------------------------------------
Fax | 630-515-1536
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24014 W RENWICK RD UNIT 206
-----------------------------------------------------
City | PLAINFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60544-8711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-974-4378
-----------------------------------------------------
Fax | 630-515-1536
-----------------------------------------------------
=====================================================
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 | 070.023928
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 298533
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 16448-24
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------