Provider Demographics
NPI:1114225059
Name:MOORE, ELIZABETH (LMT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4561 WALLACE RD
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45056-9035
Mailing Address - Country:US
Mailing Address - Phone:513-524-2637
Mailing Address - Fax:
Practice Address - Street 1:5151 MORNING SUN RD
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:OH
Practice Address - Zip Code:45056-9545
Practice Address - Country:US
Practice Address - Phone:513-523-2111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-01
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH10670174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist