1649689639 NPI number — KAREN MOORE

Table of content: KAREN MOORE (NPI 1649689639)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649689639 NPI number — KAREN MOORE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
KAREN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1649689639
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/13/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2535 HALE ST
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
AVON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44011-1856
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-934-8810
Provider Business Mailing Address Fax Number:
440-934-8811

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
26908 DETROIT RD
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
WESTLAKE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44145-2398
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-617-1823
Provider Business Practice Location Address Fax Number:
440-617-0884
Provider Enumeration Date:
08/05/2014

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: 363LG0600X , with the licence number:  16056-NP , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2200X , with the licence number: 16056-NP , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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