Basic Information
| Provider Information | |||||||||
| NPI: | 1235471491 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOON | ||||||||
| FirstName: | TAMMY | ||||||||
| MiddleName: | WADE | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 443 DILLARD RD | ||||||||
| Address2: | |||||||||
| City: | COCHRAN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310141122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4782305205 | ||||||||
| FaxNumber: | 4789349380 | ||||||||
| Practice Location | |||||||||
| Address1: | 145 E PEACOCK ST | ||||||||
| Address2: | |||||||||
| City: | COCHRAN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310147846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4789349342 | ||||||||
| FaxNumber: | 4789349380 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2013 | ||||||||
| LastUpdateDate: | 03/26/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 003113 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.