MEDICARE: STACEY MOORE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1386075331
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACEY MOORE

Provider Business Mailing Address
First Line	:	5124 ROEMER LN
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95820-3033
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5124 ROEMER LANE
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95820-3033
Country	:	US
Telephone Number	:	916-717-4995
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/02/2013
Last Update Date	:	12/02/2013

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Directions to “ STACEY MOORE ” Practice Location

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