1215669627 NPI number — REBEKAH MOORE CLC

Table of content: REBEKAH MOORE CLC (NPI 1215669627)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215669627 NPI number — REBEKAH MOORE CLC

Organization/Personal Information

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

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1215669627
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/27/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7175 E RAINTREE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT ORCHARD
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98366-7141
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-624-1694
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19950 7TH AVE NE STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POULSBO
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98370-7405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-930-0218
Provider Business Practice Location Address Fax Number:
360-930-8383
Provider Enumeration Date:
06/27/2022

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: 174N00000X , with the licence number:  339188 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 339188 . This is a "THE ACADEMY OF LACTATION POLICY AND PRACTICE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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