MEDICARE: JON MOOT PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1033744339
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JON MOOT PT

Provider Business Mailing Address
First Line	:	790 REMINGTON BLVD
Second Line	:
City	:	BOLINGBROOK
State	:	IL
Zip	:	60440-4909
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2225 E CENTENNIAL PKWY STE 106
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89081-5602
Country	:	US
Telephone Number	:	702-936-7165
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/06/2020
Last Update Date	:	03/06/2020

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Directions to “ JON MOOT PT” Practice Location

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