Provider Demographics
NPI:1992171003
Name:MOORE, GENEVA
Entity type:Individual
Prefix:
First Name:GENEVA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 34310
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48234-0310
Mailing Address - Country:US
Mailing Address - Phone:313-330-1209
Mailing Address - Fax:
Practice Address - Street 1:18714 TEPPERT ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48234-3774
Practice Address - Country:US
Practice Address - Phone:313-330-1209
Practice Address - Fax:313-521-5007
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-12
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1996046Medicaid