1215473178 NPI number — KRISTEN MICHELLE MOORE PT, DPT

Table of content: KRISTEN MICHELLE MOORE PT, DPT (NPI 1215473178)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215473178 NPI number — KRISTEN MICHELLE MOORE PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
KRISTEN
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215473178
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/07/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
10/01/2020
NPI Reactivation Date:
10/07/2020

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3063 CRESTWOOD CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAY CITY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48706-2503
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-671-7655
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
915 N RIVER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAGINAW
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48609-6865
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-781-3150
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/16/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  5501019591 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)