Healthcare Provider Details

I. General information

NPI: 1245152834
Provider Name (Legal Business Name): WILLIAM CHAD MOORE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 VETERANS DR
SAINT CLOUD MN
56303-2015
US

IV. Provider business mailing address

2563 JABER AVE NE
SAINT MICHAEL MN
55376-5405
US

V. Phone/Fax

Practice location:
  • Phone: 320-255-6390
  • Fax:
Mailing address:
  • Phone: 320-255-6390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberRN9397122
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: