Basic Information
| Provider Information | |||||||||
| NPI: | 1861415978 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 25626 | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271145626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367681270 | ||||||||
| FaxNumber: | 3367656375 | ||||||||
| Practice Location | |||||||||
| Address1: | 170 KIMEL PARK DR | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271036946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367681270 | ||||||||
| FaxNumber: | 3367656375 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 04/10/2008 | ||||||||
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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 | 4935 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 6400324 | 01 | NC | UHC PROVIDER # | OTHER | 97886 | 01 | NC | MEDCOST PROVIDER # | OTHER | 0777F | 01 | NC | BCBS PROVIDER # | OTHER | 808047 | 01 | NC | BLUE MEDICARE PROVIDER # | OTHER | P0005866 | 01 | NC | RR MEDICARE PROVIDER # | OTHER |