Provider Demographics
NPI:1114768652
Name:MOORE, BRIAN LUTHER
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:LUTHER
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11534 LOCKWOOD DR APT B2
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-2422
Mailing Address - Country:US
Mailing Address - Phone:202-852-2047
Mailing Address - Fax:
Practice Address - Street 1:11534 LOCKWOOD DR APT B2
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904-2422
Practice Address - Country:US
Practice Address - Phone:202-852-2047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-06
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD171W00000X, 372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No372600000XNursing Service Related ProvidersAdult Companion