Basic Information
| Provider Information | |||||||||
| NPI: | 1730320755 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOYAMBO | ||||||||
| FirstName: | GAOLATLHE | ||||||||
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| NamePrefix: | MR. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 WILDFLOWER BLVD | ||||||||
| Address2: | |||||||||
| City: | MARBLE FALLS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786545173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5127855295 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1900 PINE ST | ||||||||
| Address2: | |||||||||
| City: | ABILENE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 796012432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3256702000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2009 | ||||||||
| LastUpdateDate: | 03/21/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1108744 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 40QA00562300 | NJ | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT13055 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.