Provider Demographics
NPI:1851195531
Name:MOORE, JOHNNY RAY
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:RAY
Last Name:MOORE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4336 BINNEY ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68111-3040
Mailing Address - Country:US
Mailing Address - Phone:214-875-3851
Mailing Address - Fax:
Practice Address - Street 1:4336 BINNEY ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68111-3040
Practice Address - Country:US
Practice Address - Phone:214-875-3851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-02
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care