Provider Demographics
NPI:1881177566
Name:MOORE, MARY JO E (MOTRL)
Entity type:Individual
Prefix:
First Name:MARY JO
Middle Name:E
Last Name:MOORE
Suffix:
Gender:F
Credentials:MOTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 KNOLL CT
Mailing Address - Street 2:
Mailing Address - City:CORUNNA
Mailing Address - State:MI
Mailing Address - Zip Code:48817-1203
Mailing Address - Country:US
Mailing Address - Phone:989-494-8552
Mailing Address - Fax:
Practice Address - Street 1:BATTLE CREEK VA MEDICAL CENTER
Practice Address - Street 2:5500 ARMSTRONG RD
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49037
Practice Address - Country:US
Practice Address - Phone:269-223-5303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201007876225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist