Basic Information
| Provider Information | |||||||||
| NPI: | 1114124625 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | DARYL | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6979 S HOLLY CIR | ||||||||
| Address2: | STE 105 | ||||||||
| City: | CENTENNIAL | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801121577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036942295 | ||||||||
| FaxNumber: | 3036941843 | ||||||||
| Practice Location | |||||||||
| Address1: | 2375 TELSTAR DR | ||||||||
| Address2: | STE 110 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809201028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195907777 | ||||||||
| FaxNumber: | 7195907121 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 225200000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.