Provider Demographics
NPI:1659063204
Name:MOORE, RAYMOND G
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:G
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 1:596 W BURTON FARM DR
Mailing Address - Street 2:
Mailing Address - City:ARAPAHOE
Mailing Address - State:NC
Mailing Address - Zip Code:28510-1208
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6225 BRANDON AVE STE 185
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22150-2525
Practice Address - Country:US
Practice Address - Phone:703-386-7204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA23052157422251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic