Basic Information
| Provider Information | |||||||||
| NPI: | 1699145375 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | C. | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2572 W STATE ROAD 426 STE 1080 | ||||||||
| Address2: | |||||||||
| City: | OVIEDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327658300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4077965265 | ||||||||
| FaxNumber: | 4077965260 | ||||||||
| Practice Location | |||||||||
| Address1: | 2572 W STATE ROAD 426 STE 1080 | ||||||||
| Address2: | |||||||||
| City: | OVIEDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327658300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4077965265 | ||||||||
| FaxNumber: | 4077965260 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2015 | ||||||||
| LastUpdateDate: | 07/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | PT30636 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | 225100000X | PT30636 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.