Provider Demographics
NPI:1417960113
Name:MOORE, TRESA CAROL (LMT)
Entity Type:Individual
Prefix:
First Name:TRESA
Middle Name:CAROL
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:PO BOX 7191
Mailing Address - Street 2:
Mailing Address - City:RUIDOSO
Mailing Address - State:NM
Mailing Address - Zip Code:88355-7191
Mailing Address - Country:US
Mailing Address - Phone:505-937-0518
Mailing Address - Fax:
Practice Address - Street 1:201 GAVILAN CANYON ROAD
Practice Address - Street 2:
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345
Practice Address - Country:US
Practice Address - Phone:505-937-0518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3292225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist