Provider Demographics
NPI:1093127441
Name:MOORE, TRENT (DPT)
Entity Type:Individual
Prefix:
First Name:TRENT
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:816-226-4011
Mailing Address - Fax:816-524-6115
Practice Address - Street 1:1227 E 32ND ST
Practice Address - Street 2:STE 7
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-2880
Practice Address - Country:US
Practice Address - Phone:417-624-7400
Practice Address - Fax:417-624-7403
Is Sole Proprietor?:No
Enumeration Date:2014-05-20
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014019063225100000X
ARPT 3851225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA4370081OtherMEDICARE PTAN