1588024707 NPI number — BELKNAP FAMILY PRACTICE, PLLC

Table of content: REBECCA ALICE MOORE M.ED. (NPI 1285963348)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588024707 NPI number — BELKNAP FAMILY PRACTICE, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BELKNAP FAMILY PRACTICE, PLLC
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:
Provider Other Organization Name Type Code:
6
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:
1588024707
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/09/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
618 OAK ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAHAM
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76450-3040
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
940-521-1510
Provider Business Mailing Address Fax Number:
940-539-4748

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
618 OAK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAHAM
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76450-3040
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
940-521-1510
Provider Business Practice Location Address Fax Number:
940-539-4748
Provider Enumeration Date:
03/01/2016

Additional Information

Authorized Official

Authorized Official Last Name:
CLARK
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER/MANAGING MEMBER
Authorized Official Telephone Number:
940-521-1510

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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