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General NPI Number Information
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NPI Number | 1962772186
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Entity Type | Individual
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Provider Name | MELISSA RAE MOORE PTA
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Gender | Female
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Dates
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Enumeration Date | 01/04/2012
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Last Update Date | 01/04/2012
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Provider Practice Location Address
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Address Line | 401 IDAHO AVE
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City | ORDWAY
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State | CO
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Zip | 81063-1328
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Country | US
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Telephone | 877-306-0051
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Fax |
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Provider Business Mailing Address
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Address Line | 4216 SENTINEL PL
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City | PUEBLO
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State | CO
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Zip | 81008-1877
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Country | US
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Telephone | 719-423-9462
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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 | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number |
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License Number State |
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