Healthcare Provider Details

I. General information

NPI: 1659495877
Provider Name (Legal Business Name): CANDICE MOORE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 06/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W ASHLAND ST
NEVADA MO
64772-1712
US

IV. Provider business mailing address

PO BOX 1547
SEDALIA MO
65302-1547
US

V. Phone/Fax

Practice location:
  • Phone: 417-448-5800
  • Fax: 417-448-5800
Mailing address:
  • Phone: 660-826-5960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: CANDICE MOORE
Title or Position: PRESIDENT
Credential: MD
Phone: 417-448-5800