Provider Demographics
NPI:1699852442
Name:MOORE, JOE E (PT)
Entity Type:Individual
Prefix:
First Name:JOE
Middle Name:E
Last Name:MOORE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:780 PRAIRIE HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65721-7471
Mailing Address - Country:US
Mailing Address - Phone:417-300-4064
Mailing Address - Fax:
Practice Address - Street 1:780 PRAIRIE HOLLOW RD
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:MO
Practice Address - Zip Code:65721-7471
Practice Address - Country:US
Practice Address - Phone:417-300-4064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008002441225100000X
WI4746-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0007725040OtherAETNA
WI40318700Medicaid