Provider Demographics
NPI:1396871174
Name:MOOR, MICHAEL G (CPO, LPO)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:G
Last Name:MOOR
Suffix:
Gender:M
Credentials:CPO, LPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 36
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-0036
Mailing Address - Country:US
Mailing Address - Phone:503-367-3848
Mailing Address - Fax:
Practice Address - Street 1:25925 BARTON RD UNIT 36
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-5601
Practice Address - Country:US
Practice Address - Phone:503-367-3848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOI00000461222Z00000X
WAPS00000467224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR027853Medicaid
OR874024000OtherBCBS PAR, PPP, PC
OR387074301OtherPC65, FC65, PPO
OR027853Medicaid