1568432599 NPI number — COURTNEY J MOORE, PHYSICAL THERAPY, INC.

Table of content: (NPI 1568432599)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568432599 NPI number — COURTNEY J MOORE, PHYSICAL THERAPY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COURTNEY J MOORE, PHYSICAL THERAPY, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1568432599
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/19/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2251 COUNTRY CLUB LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SELMA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93662-3859
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-896-6565
Provider Business Mailing Address Fax Number:
559-896-5740

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2251 COUNTRY CLUB LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SELMA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93662-3859
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-896-6565
Provider Business Practice Location Address Fax Number:
559-896-5740
Provider Enumeration Date:
01/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MOORE
Authorized Official First Name:
COURTNEY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
559-896-6565

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  67350 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: D03592 . This is a "RR MEDICARE GROUP PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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