1528041381 NPI number — MS. BRANDI N MOORE PA

Table of content: MS. BRANDI N MOORE PA (NPI 1528041381)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528041381 NPI number — MS. BRANDI N MOORE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
BRANDI
Provider Middle Name:
N
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CANNOY
Provider Other First Name:
BRANDI
Provider Other Middle Name:
N
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1528041381
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1123 POWDER MILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IVANHOE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24350-3559
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-699-0105
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
245 FORT CHISWELL RD STE D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MAX MEADOWS
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24360-3987
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-613-6991
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/25/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  0110-002204 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 0110-002204 , 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: 10220815 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010220793 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010220807 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1068476 . This is a "NCCPA CERTIFICATE NUMBER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".