Provider Demographics
NPI:1679601199
Name:MOORE, MICHAEL D (ATC, CSCS)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:D
Last Name:MOORE
Suffix:
Gender:M
Credentials:ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 4 BOX 69
Mailing Address - Street 2:
Mailing Address - City:PHILIPPI
Mailing Address - State:WV
Mailing Address - Zip Code:26416
Mailing Address - Country:US
Mailing Address - Phone:304-457-5817
Mailing Address - Fax:
Practice Address - Street 1:50 B U DR
Practice Address - Street 2:
Practice Address - City:BUCKHANNON
Practice Address - State:WV
Practice Address - Zip Code:26201-9411
Practice Address - Country:US
Practice Address - Phone:304-472-2271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2255A2300X2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer