Healthcare Provider Details

I. General information

NPI: 1467388108
Provider Name (Legal Business Name): MR. ANTWONE MOORE JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5056 EMERSON AVE
SAINT LOUIS MO
63120-2321
US

IV. Provider business mailing address

5933 W FLORISSANT AVE
SAINT LOUIS MO
63136-4952
US

V. Phone/Fax

Practice location:
  • Phone: 314-583-9443
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: