Provider Demographics
NPI:1912387424
Name:MOORE, IVA
Entity Type:Individual
Prefix:
First Name:IVA
Middle Name:
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 1:3740 HIGHWAY 53
Mailing Address - Street 2:SUITE Y
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35806-4722
Mailing Address - Country:US
Mailing Address - Phone:256-859-0555
Mailing Address - Fax:256-859-4008
Practice Address - Street 1:3740 HIGHWAY 53
Practice Address - Street 2:SUITE Y
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35806-4722
Practice Address - Country:US
Practice Address - Phone:256-859-0555
Practice Address - Fax:256-859-4008
Is Sole Proprietor?:No
Enumeration Date:2015-06-01
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1022225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist