Healthcare Provider Details

I. General information

NPI: 1639036809
Provider Name (Legal Business Name): SHELTON MOORE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2026
Last Update Date: 01/08/2026
Certification Date: 01/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16036 N 11TH AVE UNIT 1117
PHOENIX AZ
85023-8207
US

IV. Provider business mailing address

16036 N 11TH AVE UNIT 1117
PHOENIX AZ
85023-8207
US

V. Phone/Fax

Practice location:
  • Phone: 602-473-0258
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: