MEDICARE: REBECCA MOORE MS, RD, LD, CSSD

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	133VN1501X	Sports Dietetics Nutrition Registered Dietitian

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	075BB3202	OTHER	IA	DRIVER LICENSE

General Provider Information

NPI Number	:	1477221729
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REBECCA MOORE MS, RD, LD, CSSD

Provider Business Mailing Address
First Line	:	5145 500TH ST SE
Second Line	:
City	:	IOWA CITY
State	:	IA
Zip	:	52240-8329
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	WOMACK ARMY MEDICAL CENTER 2817 REILLY ROAD
Second Line	:
City	:	FORT BRAGG
State	:	NC
Zip	:	28310-0001
Country	:	US
Telephone Number	:	225-954-8013
Fax Number	:

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

Provider Enumeration Date	:	09/01/2021
Last Update Date	:	09/02/2021

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