1417440397 NPI number — STUART MOORE LLC

Table of content: (NPI 1417440397)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417440397 NPI number — STUART MOORE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STUART MOORE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
STUART MOORE LLC
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417440397
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/14/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12050 S LAKES DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RESTON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20191-1220
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-386-0050
Provider Business Mailing Address Fax Number:
703-476-6013

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12050 S LAKES DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RESTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20191-1220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-386-0050
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/14/2018

Additional Information

Authorized Official

Authorized Official Last Name:
MOORE
Authorized Official First Name:
STUART
Authorized Official Middle Name:
COLEMAN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
703-386-0050

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  0904003326 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1346318763 . This is a "NPI" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com