Provider Demographics
NPI:1902386824
Name:MOORE, ALVITA CORINNE
Entity Type:Individual
Prefix:
First Name:ALVITA
Middle Name:CORINNE
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4140 TEXAS HIGHWAY 11 W
Mailing Address - Street 2:
Mailing Address - City:DAINGERFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:75638-7336
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:507 E W M WATSON BLVD
Practice Address - Street 2:
Practice Address - City:DAINGERFIELD
Practice Address - State:TX
Practice Address - Zip Code:75638-2013
Practice Address - Country:US
Practice Address - Phone:903-645-3915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-20
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2118351225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant