Provider Demographics
NPI:1811639321
Name:MOORE, MICHAEL JOSEPH (LAT)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:MOORE
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 WHISPERING WAY APT 193
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07747-1983
Mailing Address - Country:US
Mailing Address - Phone:201-741-8270
Mailing Address - Fax:
Practice Address - Street 1:170 RIDGEDALE AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:NJ
Practice Address - Zip Code:07940-1295
Practice Address - Country:US
Practice Address - Phone:973-593-3117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-13
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT002857002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer