Provider Demographics
NPI:1124336490
Name:MOORE, STACI JENNIFER (DPT)
Entity type:Individual
Prefix:DR
First Name:STACI
Middle Name:JENNIFER
Last Name:MOORE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 CORPORATE CENTER DR.
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91768
Mailing Address - Country:US
Mailing Address - Phone:909-623-1954
Mailing Address - Fax:909-623-4988
Practice Address - Street 1:801 CORPORATE CENTER DR.
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91768
Practice Address - Country:US
Practice Address - Phone:909-623-1954
Practice Address - Fax:909-623-4988
Is Sole Proprietor?:No
Enumeration Date:2010-09-20
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36505225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist