Provider Demographics
NPI:1942374723
Name:CHAD A MOORE PT LLC
Entity Type:Organization
Organization Name:CHAD A MOORE PT LLC
Other - Org Name:MOORE PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:A
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:928-225-0287
Mailing Address - Street 1:3819 E FOXTAIL DR
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-7697
Mailing Address - Country:US
Mailing Address - Phone:928-225-0287
Mailing Address - Fax:
Practice Address - Street 1:3819 E FOXTAIL DR
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-7697
Practice Address - Country:US
Practice Address - Phone:928-225-0287
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6193225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ127444Medicaid
AZ127444Medicaid
AZZ152327Medicare PIN