MEDICARE: DARYL MOORE PTA

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	225200000X	Physical Therapy Assistant

General Provider Information

NPI Number	:	1114124625
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DARYL MOORE PTA

Provider Business Mailing Address
First Line	:	6979 S HOLLY CIR
Second Line	:	STE 105
City	:	CENTENNIAL
State	:	CO
Zip	:	80112-1577
Country	:	US
Telephone Number	:	303-694-2295
Fax Number	:	303-694-1843

Provider Business Practice Location Address
First Line	:	2375 TELSTAR DR
Second Line	:	STE 110
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80920-1028
Country	:	US
Telephone Number	:	719-590-7777
Fax Number	:	719-590-7121

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

Provider Enumeration Date	:	06/28/2007
Last Update Date	:	07/08/2007

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Directions to “ DARYL MOORE PTA” Practice Location

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