Healthcare Provider Details

I. General information

NPI: 1164773040
Provider Name (Legal Business Name): MR. GERRY DELAYNE MOORE SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2012
Last Update Date: 10/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 RENDI LN
BAXLEY GA
31513-6816
US

IV. Provider business mailing address

85 RENDI LN
BAXLEY GA
31513-6816
US

V. Phone/Fax

Practice location:
  • Phone: 912-347-9043
  • Fax: 912-367-0986
Mailing address:
  • Phone: 912-347-9043
  • Fax: 912-367-0986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: