Provider Demographics
NPI:1194318931
Name:MOORE, CHARLES
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:MOORE
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 1:354 HOLLY AVE
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03103-4645
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13 MARCH FARM WAY UNIT C
Practice Address - Street 2:
Practice Address - City:GREENLAND
Practice Address - State:NH
Practice Address - Zip Code:03840-6235
Practice Address - Country:US
Practice Address - Phone:603-380-7174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-12
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist