Basic Information
| Provider Information | |||||||||
| NPI: | 1275727422 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | PATRICK | ||||||||
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| Credential: | RPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13 NORTHTOWN DR | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392113047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012069195 | ||||||||
| FaxNumber: | 6019578391 | ||||||||
| Practice Location | |||||||||
| Address1: | 13 NORTHTOWN DR | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392113047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012069195 | ||||||||
| FaxNumber: | 6019578391 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2007 | ||||||||
| LastUpdateDate: | 08/30/2007 | ||||||||
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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 | 225100000X | PT3269 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.