Provider Demographics
NPI:1609241819
Name:MOORE, BENJAMIN
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2207 N MOLTER RD STE 250
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-7582
Mailing Address - Country:US
Mailing Address - Phone:509-893-9939
Mailing Address - Fax:509-893-9107
Practice Address - Street 1:2207 N MOLTER RD STE 250
Practice Address - Street 2:
Practice Address - City:LIBERTY LAKE
Practice Address - State:WA
Practice Address - Zip Code:99019-7582
Practice Address - Country:US
Practice Address - Phone:509-893-9939
Practice Address - Fax:509-893-9107
Is Sole Proprietor?:No
Enumeration Date:2015-12-14
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60614122225700000X
IDMAS-2802225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist