Provider Demographics
NPI:1588876247
Name:MOORE, RICHARD EUGENE JR (MPT, ATC)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:EUGENE
Last Name:MOORE
Suffix:JR
Gender:M
Credentials:MPT, ATC
Other - Prefix:MR
Other - First Name:RICHARD
Other - Middle Name:EUGENE
Other - Last Name:MOORE
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:MPT, ATC
Mailing Address - Street 1:1410 BEACON HL
Mailing Address - Street 2:
Mailing Address - City:AFTON
Mailing Address - State:VA
Mailing Address - Zip Code:22920-9600
Mailing Address - Country:US
Mailing Address - Phone:434-249-3756
Mailing Address - Fax:
Practice Address - Street 1:4416 IVY COMMONS
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-7123
Practice Address - Country:US
Practice Address - Phone:434-249-3756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305202139225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA00X575E01Medicare PIN