Provider Demographics
NPI:1194115816
Name:MOODY, JUSTIN
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:MOODY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 COUNTY ROAD 428
Mailing Address - Street 2:
Mailing Address - City:DOUBLE SPRINGS
Mailing Address - State:AL
Mailing Address - Zip Code:35553-4943
Mailing Address - Country:US
Mailing Address - Phone:205-272-0841
Mailing Address - Fax:
Practice Address - Street 1:560 DEVALL DR
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:AL
Practice Address - Zip Code:36832-5813
Practice Address - Country:US
Practice Address - Phone:205-272-0841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-02
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL16252255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer