Provider Demographics
NPI:1578109641
Name:MOORE, MICHAEL (ATC, PTA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:ATC, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3910 S CAREFREE CIR STE B
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-3053
Mailing Address - Country:US
Mailing Address - Phone:719-457-6001
Mailing Address - Fax:
Practice Address - Street 1:3910 S CAREFREE CIR STE B
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917-3053
Practice Address - Country:US
Practice Address - Phone:719-457-6001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-22
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225200000X
COAT.00005022255A2300X
COPTA.0012277225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer