MEDICARE: MRS. RENA ANN MOORE OTRL

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	5201009053	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1780257014
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. RENA ANN MOORE OTRL

Provider Business Mailing Address
First Line	:	2600 COMPASS RD
Second Line	:
City	:	GLENVIEW
State	:	IL
Zip	:	60026-8001
Country	:	US
Telephone Number	:	877-787-3430
Fax Number	:

Provider Business Practice Location Address
First Line	:	695 MITZI ST
Second Line	:
City	:	MUSKEGON
State	:	MI
Zip	:	49445-3232
Country	:	US
Telephone Number	:	231-744-1641
Fax Number	:

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

Provider Enumeration Date	:	07/23/2021
Last Update Date	:	07/23/2021

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