Healthcare Provider Details

I. General information

NPI: 1780769489
Provider Name (Legal Business Name): DARLENE A MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 07/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 W LIBERTY ST
FARMINGTON MO
63640-1921
US

IV. Provider business mailing address

670 MASON RIDGE CENTER DR STE 300
SAINT LOUIS MO
63141-8573
US

V. Phone/Fax

Practice location:
  • Phone: 573-756-6751
  • Fax: 573-756-1965
Mailing address:
  • Phone: 573-756-6751
  • Fax: 573-756-1965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR6D31
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: