Provider Demographics
NPI:1992442552
Name:MOORE, DAMIAN DARRYL (LPT)
Entity type:Individual
Prefix:
First Name:DAMIAN
Middle Name:DARRYL
Last Name:MOORE
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5604 N E ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92407-2626
Mailing Address - Country:US
Mailing Address - Phone:909-341-3865
Mailing Address - Fax:
Practice Address - Street 1:1481 WINDSOR DR
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-5416
Practice Address - Country:US
Practice Address - Phone:909-361-6470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-16
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42031167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician