MEDICARE: ROSLYN 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	385HR2055X	Child Mental Illness Respite Care	8559	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	917057	OTHER	AZ	AHCCCS ID

General Provider Information

NPI Number	:	1588731970
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROSLYN MOORE

Provider Business Mailing Address
First Line	:	3132 W ALTA VISTA RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85041-5209
Country	:	US
Telephone Number	:	623-873-0204
Fax Number	:

Provider Business Practice Location Address
First Line	:	3132 W ALTA VISTA RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85041-5209
Country	:	US
Telephone Number	:	623-873-0204
Fax Number	:

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

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	07/08/2007

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Directions to “ ROSLYN MOORE ” Practice Location

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