Healthcare Provider Details

I. General information

NPI: 1578007761
Provider Name (Legal Business Name): JOHN JAMES MOORE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2016
Last Update Date: 12/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3830 HIGGINS ST
LOVELAND CO
80538-4960
US

IV. Provider business mailing address

3830 HIGGINS ST
LOVELAND CO
80538-4960
US

V. Phone/Fax

Practice location:
  • Phone: 308-464-0824
  • Fax:
Mailing address:
  • Phone: 308-464-0824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License NumberMP00179558
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: