1790742021 NPI number — MRS. COLEEN LEANN MOORE PT

Table of content: MRS. COLEEN LEANN MOORE PT (NPI 1790742021)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790742021 NPI number — MRS. COLEEN LEANN MOORE PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
COLEEN
Provider Middle Name:
LEANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1790742021
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 841
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HARRISON
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72602-0841
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-743-5573
Provider Business Mailing Address Fax Number:
870-743-5974

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1801 FOREST HILLS BLVD
Provider Second Line Business Practice Location Address:
STE 205
Provider Business Practice Location Address City Name:
BELLA VISTA
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72715
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-855-9348
Provider Business Practice Location Address Fax Number:
479-855-9358
Provider Enumeration Date:
04/28/2006

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:  PT388 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5T496 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".




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