1972789535 NPI number — ANN JOLENE MOORE L.C.P.C.

Table of content: ANN JOLENE MOORE L.C.P.C. (NPI 1972789535)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972789535 NPI number — ANN JOLENE MOORE L.C.P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
ANN
Provider Middle Name:
JOLENE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
L.C.P.C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BARRUS
Provider Other First Name:
ANN
Provider Other Middle Name:
JOLENE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1972789535
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/02/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4696 W OVERLAND RD
Provider Second Line Business Mailing Address:
SUITE 118
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83705-2845
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-841-3581
Provider Business Mailing Address Fax Number:
208-906-8572

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4696 W OVERLAND RD
Provider Second Line Business Practice Location Address:
SUITE 118
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83705-2845
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-841-3581
Provider Business Practice Location Address Fax Number:
208-906-8572
Provider Enumeration Date:
01/14/2008

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: 101YM0800X , with the licence number:  LCPC-3938 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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