Healthcare Provider Details

I. General information

NPI: 1194519207
Provider Name (Legal Business Name): MICHAEL LEMUEL MOORE SR. B.A., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2025
Last Update Date: 04/05/2025
Certification Date: 04/05/2025
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: 925-450-8182
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: