Healthcare Provider Details

I. General information

NPI: 1053851147
Provider Name (Legal Business Name): SHATORIA MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2017
Last Update Date: 08/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 HOMER RD
MINDEN LA
71055
US

IV. Provider business mailing address

3625 YOUREE DR
SHREVEPORT LA
71105-2121
US

V. Phone/Fax

Practice location:
  • Phone: 318-639-9562
  • Fax:
Mailing address:
  • Phone: 318-742-3408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: