Provider Demographics
NPI:1225418999
Name:MOORE, SAMUEL L (PT, DPT)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:L
Last Name:MOORE
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 COUNTRY CLUB PKWY
Mailing Address - Street 2:
Mailing Address - City:SPRING CREEK
Mailing Address - State:NV
Mailing Address - Zip Code:89815-5830
Mailing Address - Country:US
Mailing Address - Phone:775-777-1276
Mailing Address - Fax:775-777-7022
Practice Address - Street 1:250 COUNTRY CLUB PKWY
Practice Address - Street 2:
Practice Address - City:SPRING CREEK
Practice Address - State:NV
Practice Address - Zip Code:89815-5830
Practice Address - Country:US
Practice Address - Phone:775-777-1276
Practice Address - Fax:775-777-7022
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-08
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3139225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV111084Medicare PIN