Provider Demographics
NPI:1316701352
Name:MOORE, DOUGLAS LEROY JR
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:LEROY
Last Name:MOORE
Suffix:JR
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 1:131 E MAIN ST APT 304
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:WV
Mailing Address - Zip Code:26354-1383
Mailing Address - Country:US
Mailing Address - Phone:304-698-9544
Mailing Address - Fax:
Practice Address - Street 1:131 E MAIN ST APT 304
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WV
Practice Address - Zip Code:26354-1383
Practice Address - Country:US
Practice Address - Phone:304-698-9544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-09
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant