Basic Information
| Provider Information | |||||||||
| NPI: | 1902003510 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | SCOTT | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS, ATC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MOORE | ||||||||
| OtherFirstName: | JODY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MS, ATC | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 50 HILLCREST MEDICAL BLVD | ||||||||
| Address2: | STE. 303 | ||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767128952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2547411400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 50 HILLCREST MEDICAL BLVD | ||||||||
| Address2: | STE. 303 | ||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767128952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2547411400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2007 | ||||||||
| LastUpdateDate: | 03/17/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 120502002 | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.