1770753360 NPI number — BOBBYE JEAN MOORE CATC

Table of content: BOBBYE JEAN MOORE CATC (NPI 1770753360)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770753360 NPI number — BOBBYE JEAN MOORE CATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
BOBBYE
Provider Middle Name:
JEAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CATC
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:
1770753360
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/12/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1073 SPARROW LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAIRFIELD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94533-2429
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-718-6027
Provider Business Mailing Address Fax Number:
707-759-4515

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2290 DIAMOND BLVD STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONCORD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94520-5742
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
925-798-7250
Provider Business Practice Location Address Fax Number:
925-798-3359
Provider Enumeration Date:
03/10/2008

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: 101YA0400X , with the licence number:  M1007281844 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4838 . This is a "DRUG MEDICAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".