Basic Information
Provider Information | |||||||||
NPI: | 1982864849 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MOORE PEDIATRIC THERAPY SERVICES, PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 354 | ||||||||
Address2: |   | ||||||||
City: | WEST END | ||||||||
State: | NC | ||||||||
PostalCode: | 273760354 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9106735437 | ||||||||
FaxNumber: | 9106735438 | ||||||||
Practice Location | |||||||||
Address1: | 1163 SEVEN LAKES DR | ||||||||
Address2: |   | ||||||||
City: | WEST END | ||||||||
State: | NC | ||||||||
PostalCode: | 27376 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9106735437 | ||||||||
FaxNumber: | 9106735438 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/13/2008 | ||||||||
LastUpdateDate: | 11/01/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SECURA | ||||||||
AuthorizedOfficialFirstName: | CYNTHIA | ||||||||
AuthorizedOfficialMiddleName: | C | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER/OPERATOR | ||||||||
AuthorizedOfficialTelephone: | 9106735437 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XP0200X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics | 235Z00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   | 174400000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 7200169 | 05 | NC |   | MEDICAID |