Provider Demographics
NPI:1700250495
Name:MOORE, TIFFANY (LMT)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2939 KENNY RD
Mailing Address - Street 2:SUITE 195
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43221-2406
Mailing Address - Country:US
Mailing Address - Phone:937-418-5545
Mailing Address - Fax:
Practice Address - Street 1:2930 E LEFFEL LN
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45505-4540
Practice Address - Country:US
Practice Address - Phone:937-418-5545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-18
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.016454225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist