Provider Demographics
NPI:1427695857
Name:MOORE, FREDERICK HENRY JR
Entity type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:HENRY
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 1:38511 WELLINGTON DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48036-3520
Mailing Address - Country:US
Mailing Address - Phone:586-260-6371
Mailing Address - Fax:
Practice Address - Street 1:14000 LAKESIDE CIR
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313-1320
Practice Address - Country:US
Practice Address - Phone:586-260-6371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-04
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI27014933431744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty