Provider Demographics
NPI:1902277692
Name:MOORE, MICHEAL
Entity type:Individual
Prefix:
First Name:MICHEAL
Middle Name:
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 1:104 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92415-0035
Mailing Address - Country:US
Mailing Address - Phone:909-382-7880
Mailing Address - Fax:
Practice Address - Street 1:104 W 4TH ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92415-3222
Practice Address - Country:US
Practice Address - Phone:909-382-7880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-07
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator