Provider Demographics
NPI:1104130780
Name:MOORE TRANSPORT OF OFALLON LLC
Entity type:Organization
Organization Name:MOORE TRANSPORT OF OFALLON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEJA
Authorized Official - Middle Name:ENJOLI
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:636-757-3021
Mailing Address - Street 1:7597 PIERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-7028
Mailing Address - Country:US
Mailing Address - Phone:636-633-2888
Mailing Address - Fax:636-294-5435
Practice Address - Street 1:7597 PIERSIDE DR
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-7028
Practice Address - Country:US
Practice Address - Phone:636-633-2888
Practice Address - Fax:636-294-5435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-05
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOPO52355003343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)