MEDICARE: NICOLE 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	225X00000X	Occupational Therapist	17966	FL
2	225X00000X	Occupational Therapist	7839	SC

General Provider Information

NPI Number	:	1972050243
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE MOORE

Provider Business Mailing Address
First Line	:	4381 CHARLOTTE HWY STE 104
Second Line	:
City	:	LAKE WYLIE
State	:	SC
Zip	:	29710-7061
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4381 CHARLOTTE HWY STE 104
Second Line	:
City	:	LAKE WYLIE
State	:	SC
Zip	:	29710-7061
Country	:	US
Telephone Number	:	803-631-5485
Fax Number	:

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

Provider Enumeration Date	:	09/05/2016
Last Update Date	:	01/29/2026

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Directions to “ NICOLE MOORE ” Practice Location

Language	Start Address	Practice Location

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