Provider Demographics
NPI:1528398989
Name:MOORE, BRYAN ANDERSON (PT)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:ANDERSON
Last Name:MOORE
Suffix:
Gender:M
Credentials:PT
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 5777
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71135-5777
Mailing Address - Country:US
Mailing Address - Phone:318-322-7050
Mailing Address - Fax:318-322-7031
Practice Address - Street 1:1815 ROSELAWN AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5433
Practice Address - Country:US
Practice Address - Phone:318-322-7050
Practice Address - Fax:318-322-7031
Is Sole Proprietor?:No
Enumeration Date:2010-01-07
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist