Provider Demographics
NPI:1336328160
Name:EUGENE R MOE PT PC
Entity Type:Organization
Organization Name:EUGENE R MOE PT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-265-4252
Mailing Address - Street 1:1010 SW COAST HWY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:NEWPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97365-5288
Mailing Address - Country:US
Mailing Address - Phone:541-265-4252
Mailing Address - Fax:541-265-8914
Practice Address - Street 1:1010 SW COAST HWY
Practice Address - Street 2:SUITE 102
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-5288
Practice Address - Country:US
Practice Address - Phone:541-265-4252
Practice Address - Fax:541-265-8914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0958174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR117513Medicare UPIN