Basic Information
| Provider Information | |||||||||
| NPI: | 1265523161 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | LOU ANN | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10019 WICKER PARK PL | ||||||||
| Address2: | |||||||||
| City: | PALMETTO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342211109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282014055 | ||||||||
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| Practice Location | |||||||||
| Address1: | 129 S PEBBLE BEACH BLVD | ||||||||
| Address2: | |||||||||
| City: | SUN CITY CENTER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335735718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136336800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 11/21/2016 | ||||||||
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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 | PT18899 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 888827200 | 05 | FL | MEDICAID |