Provider Demographics
NPI:1457398786
Name:MOORE, DAVID GLEN (PT)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:GLEN
Last Name:MOORE
Suffix:
Gender:M
Credentials:PT
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Mailing Address - Street 1:2175 NORTHLAKE PARKWAY
Mailing Address - Street 2:SUITE 137
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084
Mailing Address - Country:US
Mailing Address - Phone:770-908-0740
Mailing Address - Fax:770-908-0463
Practice Address - Street 1:5755 NORTH POINT PARKWAY
Practice Address - Street 2:SUITE 56
Practice Address - City:ALPAHRETTA
Practice Address - State:GA
Practice Address - Zip Code:30022
Practice Address - Country:US
Practice Address - Phone:770-908-0740
Practice Address - Fax:770-908-0463
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2011-12-22
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA65BBDKVMedicare PIN
GA511I650246Medicare PIN