Provider Demographics
NPI:1619020427
Name:MOORE, MICHAEL RILEY (BOC P ABC CFO)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:RILEY
Last Name:MOORE
Suffix:
Gender:M
Credentials:BOC P ABC CFO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 W GROVE ST
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:AR
Mailing Address - Zip Code:71730-4413
Mailing Address - Country:US
Mailing Address - Phone:870-862-0241
Mailing Address - Fax:903-838-8094
Practice Address - Street 1:615 W GROVE ST
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730-4413
Practice Address - Country:US
Practice Address - Phone:870-862-0241
Practice Address - Fax:903-838-8094
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROPP00120224P00000X, 222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist