Provider Demographics
NPI:1558110965
Name:MOORE, CHELE (MT)
Entity type:Individual
Prefix:
First Name:CHELE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2934 1/2 N BEVERLY GLEN CIR UNIT 448
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077-1745
Mailing Address - Country:US
Mailing Address - Phone:310-770-8233
Mailing Address - Fax:
Practice Address - Street 1:1619 1/2 MONTANA AVE STE A
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-1807
Practice Address - Country:US
Practice Address - Phone:310-770-8233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-16
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA90495225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty