Provider Demographics
NPI:1730320755
Name:MOYAMBO, GAOLATLHE (PT)
Entity Type:Individual
Prefix:MR
First Name:GAOLATLHE
Middle Name:
Last Name:MOYAMBO
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 1:101 WILDFLOWER BLVD
Mailing Address - Street 2:
Mailing Address - City:MARBLE FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:78654-5173
Mailing Address - Country:US
Mailing Address - Phone:512-785-5295
Mailing Address - Fax:
Practice Address - Street 1:1900 PINE ST
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79601-2432
Practice Address - Country:US
Practice Address - Phone:325-670-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-21
Last Update Date:2009-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1108744225100000X
NJ40QA00562300225100000X
FLPT13055225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist