MEDICARE: MR. JUAN CARLOS 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	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1386997922
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JUAN CARLOS MOORE

Provider Business Mailing Address
First Line	:	9121 N COUNCIL RD
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73132-1300
Country	:	US
Telephone Number	:	405-408-1216
Fax Number	:	405-470-3428

Provider Business Practice Location Address
First Line	:	9121 N COUNCIL RD
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73132-1300
Country	:	US
Telephone Number	:	405-408-1216
Fax Number	:	405-470-3428

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

Provider Enumeration Date	:	10/19/2012
Last Update Date	:	02/07/2013

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Directions to “ MR. JUAN CARLOS MOORE ” Practice Location

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