Provider Demographics
NPI:1124451257
Name:MOORE, BRUCE KHALIL II (EMT)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:KHALIL
Last Name:MOORE
Suffix:II
Gender:M
Credentials:EMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 SALEM AVE
Mailing Address - Street 2:
Mailing Address - City:HILLSIDE
Mailing Address - State:NJ
Mailing Address - Zip Code:07120
Mailing Address - Country:US
Mailing Address - Phone:973-558-6942
Mailing Address - Fax:
Practice Address - Street 1:1101 SALEM AVE
Practice Address - Street 2:
Practice Address - City:HILLSIDE
Practice Address - State:NJ
Practice Address - Zip Code:07205-2834
Practice Address - Country:US
Practice Address - Phone:973-558-6942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-13
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2012045341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance