Provider Demographics
NPI:1306477518
Name:MOORE, SAM EUGENE JR (AMBULETTE)
Entity type:Individual
Prefix:MR
First Name:SAM
Middle Name:EUGENE
Last Name:MOORE
Suffix:JR
Gender:M
Credentials:AMBULETTE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 DU BOIS AVE
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601-2140
Mailing Address - Country:US
Mailing Address - Phone:845-464-4162
Mailing Address - Fax:
Practice Address - Street 1:33 DU BOIS AVE
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-2140
Practice Address - Country:US
Practice Address - Phone:845-464-4162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5363887522172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty