MEDICARE: MR. DAVE JAMES MOORE OTR/L

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	225XE1200X	Ergonomics Occupational Therapist	4262-026	WI

General Provider Information

NPI Number	:	1932369121
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DAVE JAMES MOORE OTR/L

Provider Business Mailing Address
First Line	:	3128 WILDFLOWER LN
Second Line	:
City	:	JACKSON
State	:	WI
Zip	:	53037-8928
Country	:	US
Telephone Number	:	262-510-7277
Fax Number	:

Provider Business Practice Location Address
First Line	:	807 PLEASANT VALLEY RD
Second Line	:
City	:	WEST BEND
State	:	WI
Zip	:	53095-9767
Country	:	US
Telephone Number	:	262-675-6533
Fax Number	:

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

Provider Enumeration Date	:	06/11/2008
Last Update Date	:	06/11/2008

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