MEDICARE: MS. LEEANN MOORE

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number State
1	385H00000X	Respite Care
2	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility
3	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	NJ

General Provider Information

NPI Number	:	1699419556
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LEEANN MOORE

Provider Business Mailing Address
First Line	:	210 4TH ST
Second Line	:
City	:	W.KEANSBURG
State	:	NJ
Zip	:	07734-2918
Country	:	US
Telephone Number	:	732-768-7227
Fax Number	:

Provider Business Practice Location Address
First Line	:	210 4TH ST
Second Line	:
City	:	HAZLET TOWNSHIP
State	:	NJ
Zip	:	07734-2918
Country	:	US
Telephone Number	:	732-768-7227
Fax Number	:

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

Provider Enumeration Date	:	04/26/2022
Last Update Date	:	09/18/2023

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