MEDICARE: MRS. LYNN MARIE MOORE O.T.R.

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	225X00000X	Occupational Therapist	2114	NM

General Provider Information

NPI Number	:	1275731630
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LYNN MARIE MOORE O.T.R.

Provider Business Mailing Address
First Line	:	48 DERBYSHIRE RD
Second Line	:
City	:	TULAROSA
State	:	NM
Zip	:	88352-9501
Country	:	US
Telephone Number	:	505-585-4998
Fax Number	:	505-585-4998

Provider Business Practice Location Address
First Line	:	3101 N FLORIDA AVE
Second Line	:
City	:	ALAMOGORDO
State	:	NM
Zip	:	88310-9713
Country	:	US
Telephone Number	:	505-434-0033
Fax Number	:

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

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

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