MEDICARE: ONDRELL MOORE

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	007284	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	007284	OTHER	GA	STATE LISC#

General Provider Information

NPI Number	:	1306906532
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ONDRELL MOORE

Provider Business Mailing Address
First Line	:	PO BOX 518
Second Line	:
City	:	JONESBORO
State	:	GA
Zip	:	30237-0518
Country	:	US
Telephone Number	:	770-631-8277
Fax Number	:	770-631-9403

Provider Business Practice Location Address
First Line	:	939 THORNTON RD
Second Line	:
City	:	LITHIA SPRINGS
State	:	GA
Zip	:	30122-2634
Country	:	US
Telephone Number	:	770-739-3880
Fax Number	:

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

Provider Enumeration Date	:	12/11/2006
Last Update Date	:	07/08/2007

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Directions to “ ONDRELL MOORE ” Practice Location

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