1316155633 NPI number — DR. LAFACIAL WILSON MOORE PH.D.

Table of content: DR. LAFACIAL WILSON MOORE PH.D. (NPI 1316155633)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316155633 NPI number — DR. LAFACIAL WILSON MOORE PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
LAFACIAL
Provider Middle Name:
WILSON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WILSON
Provider Other First Name:
LAFACIAL
Provider Other Middle Name:
YVETTE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PH.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1316155633
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/13/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
924 MONTCLAIR RD
Provider Second Line Business Mailing Address:
SUITE 106
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35213-1211
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-218-9398
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
924 MONTCLAIR RD
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
BIRMINGHAM
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35213-1211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-218-9398
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/18/2007

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: 101YP2500X , with the licence number:  2364 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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