Provider Demographics
NPI:1104900620
Name:MOORE, MICHAEL J (PT FFAAOMPT)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:J
Last Name:MOORE
Suffix:
Gender:M
Credentials:PT FFAAOMPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:115 NATOMA ST
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630
Mailing Address - Country:US
Mailing Address - Phone:916-355-8196
Mailing Address - Fax:916-355-8196
Practice Address - Street 1:115 NATOMA ST
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630
Practice Address - Country:US
Practice Address - Phone:916-355-8196
Practice Address - Fax:916-355-8196
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7554225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PT7554OtherBLUE CROSS OF CA
OPT75540OtherBLUE SHIELD
PT7554OtherBLUE CROSS OF CA