Healthcare Provider Details

I. General information

NPI: 1174326383
Provider Name (Legal Business Name): JUSTIN TODD MOORE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2025
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 SPRINGHILL DR STE 100
NORTH LITTLE ROCK AR
72117-2905
US

IV. Provider business mailing address

3201 SPRINGHILL DR STE 100
NORTH LITTLE ROCK AR
72117-2905
US

V. Phone/Fax

Practice location:
  • Phone: 501-202-3000
  • Fax:
Mailing address:
  • Phone: 816-803-8158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: