1770729550 NPI number — MRS. TYNA LEE MOORE N.D., D.C.

Table of content: MRS. TYNA LEE MOORE N.D., D.C. (NPI 1770729550)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770729550 NPI number — MRS. TYNA LEE MOORE N.D., D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
TYNA
Provider Middle Name:
LEE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
N.D., D.C.
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:
1770729550
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10200 SW EASTRIDGE ST
Provider Second Line Business Mailing Address:
STE 135
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97225-5064
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-644-4446
Provider Business Mailing Address Fax Number:
503-644-1993

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10200 SW EASTRIDGE ST
Provider Second Line Business Practice Location Address:
STE 135
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97225-5064
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-644-4446
Provider Business Practice Location Address Fax Number:
503-644-1993
Provider Enumeration Date:
12/27/2008

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: 175F00000X , with the licence number:  1637 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 111N00000X , with the licence number: 3932 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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