Healthcare Provider Details

I. General information

NPI: 1922810498
Provider Name (Legal Business Name): DEMETRIUS MOORE ND
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2025
Last Update Date: 01/29/2025
Certification Date: 01/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 W CROSSVILLE RD STE 200
ROSWELL GA
30075-2539
US

IV. Provider business mailing address

1398 KEYHAVEN CT
LAWRENCEVILLE GA
30045-2797
US

V. Phone/Fax

Practice location:
  • Phone: 470-749-6107
  • Fax:
Mailing address:
  • Phone: 470-749-6107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code175L00000X
TaxonomyHomeopath
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: