1699800136 NPI number — MR. BURL RODDY MOORE BS DEGREE PSYC.

Table of content: MR. BURL RODDY MOORE BS DEGREE PSYC. (NPI 1699800136)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699800136 NPI number — MR. BURL RODDY MOORE BS DEGREE PSYC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
BURL
Provider Middle Name:
RODDY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
BS DEGREE PSYC.
Provider Gender Code:
M

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:
1699800136
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5317 S CORNING AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90056-1105
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-787-1500
Provider Business Mailing Address Fax Number:
310-787-9713

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5317 CORNING AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90056
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-787-1500
Provider Business Practice Location Address Fax Number:
310-787-9713
Provider Enumeration Date:
02/23/2007

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: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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