Provider Demographics
NPI:1962772186
Name:MOORE, MELISSA RAE (PTA)
Entity type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:RAE
Last Name:MOORE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4216 SENTINEL PL
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-1877
Mailing Address - Country:US
Mailing Address - Phone:719-423-9462
Mailing Address - Fax:
Practice Address - Street 1:401 IDAHO AVE
Practice Address - Street 2:
Practice Address - City:ORDWAY
Practice Address - State:CO
Practice Address - Zip Code:81063-1328
Practice Address - Country:US
Practice Address - Phone:877-306-0051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-04
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization