MEDICARE: DUSTIN MOORE DPT

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	1264941	TX

General Provider Information

NPI Number	:	1417325275
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DUSTIN MOORE DPT

Provider Business Mailing Address
First Line	:	12500 SOUTH FWY
Second Line	:	SUITE 201
City	:	BURLESON
State	:	TX
Zip	:	76028-7130
Country	:	US
Telephone Number	:	817-447-2323
Fax Number	:	817-447-3311

Provider Business Practice Location Address
First Line	:	12500 SOUTH FWY
Second Line	:	SUITE 201
City	:	BURLESON
State	:	TX
Zip	:	76028-7130
Country	:	US
Telephone Number	:	817-447-2323
Fax Number	:	817-447-3311

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

Provider Enumeration Date	:	09/10/2015
Last Update Date	:	09/10/2015

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