Provider Demographics
NPI:1992466411
Name:MOORE, LANCE KENNETH (PT, DPT)
Entity type:Individual
Prefix:
First Name:LANCE
Middle Name:KENNETH
Last Name:MOORE
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 S GLOSTER ST STE C
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-6548
Mailing Address - Country:US
Mailing Address - Phone:662-432-1523
Mailing Address - Fax:
Practice Address - Street 1:1211 S GLOSTER ST STE C
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6548
Practice Address - Country:US
Practice Address - Phone:662-432-1523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-06
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT7251225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist