Healthcare Provider Details

I. General information

NPI: 1750839577
Provider Name (Legal Business Name): MIKE MOORE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2016
Last Update Date: 11/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2053 GAUSE BLVD E STE 150
SLIDELL LA
70461-5451
US

IV. Provider business mailing address

500 FAIRWAY DR STE 102
DEERFIELD BEACH FL
33441-1817
US

V. Phone/Fax

Practice location:
  • Phone: 985-445-3089
  • Fax:
Mailing address:
  • Phone: 888-880-9270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: