Provider Demographics
NPI:1720824808
Name:MOORE, JEFFERY LAMAN
Entity type:Individual
Prefix:
First Name:JEFFERY
Middle Name:LAMAN
Last Name:MOORE
Suffix:
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 1:25523 RILEY CIR
Mailing Address - Street 2:
Mailing Address - City:ROMOLAND
Mailing Address - State:CA
Mailing Address - Zip Code:92585-8885
Mailing Address - Country:US
Mailing Address - Phone:619-302-6567
Mailing Address - Fax:
Practice Address - Street 1:25523 RILEY CIR
Practice Address - Street 2:
Practice Address - City:ROMOLAND
Practice Address - State:CA
Practice Address - Zip Code:92585-8885
Practice Address - Country:US
Practice Address - Phone:619-302-6567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker