Provider Demographics
NPI:1093068884
Name:MOORE, MARTINA MARIA (LAC)
Entity Type:Individual
Prefix:MRS
First Name:MARTINA
Middle Name:MARIA
Last Name:MOORE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8143 S WABASH AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60619-4705
Mailing Address - Country:US
Mailing Address - Phone:773-216-3146
Mailing Address - Fax:
Practice Address - Street 1:8143 S WABASH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619-4705
Practice Address - Country:US
Practice Address - Phone:773-216-3146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-18
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198000579171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist