Provider Demographics
NPI:1215710843
Name:MOORE, SANDRA J
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:J
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14256 CLOVERLAWN ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48238-2430
Mailing Address - Country:US
Mailing Address - Phone:313-407-2198
Mailing Address - Fax:
Practice Address - Street 1:25545 BRIAR DR
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-1335
Practice Address - Country:US
Practice Address - Phone:313-407-2198
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-16
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide