Healthcare Provider Details

I. General information

NPI: 1356884852
Provider Name (Legal Business Name): MR. MICHAEL LEMUEL MOORE II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2016
Last Update Date: 08/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

665 ROTUNDA WAY
BRENTWOOD CA
94513-5534
US

IV. Provider business mailing address

665 ROTUNDA WAY
BRENTWOOD CA
94513-5534
US

V. Phone/Fax

Practice location:
  • Phone: 510-502-1667
  • Fax:
Mailing address:
  • Phone: 510-502-1667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: