Healthcare Provider Details

I. General information

NPI: 1386952562
Provider Name (Legal Business Name): MELITA N. MOORE,MD INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2010
Last Update Date: 09/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2825 J ST SUITE 440
SACRAMENTO CA
95816-4300
US

IV. Provider business mailing address

2825 J ST SUITE 440
SACRAMENTO CA
95816-4300
US

V. Phone/Fax

Practice location:
  • Phone: 916-492-2110
  • Fax: 916-492-2111
Mailing address:
  • Phone: 916-492-2110
  • Fax: 916-492-2111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberA108599
License Number StateCA

VIII. Authorized Official

Name: DR. MELITA N MOORE
Title or Position: CEO
Credential: MD
Phone: 916-492-2110