Healthcare Provider Details

I. General information

NPI: 1346595154
Provider Name (Legal Business Name): ROBERT KEITH MOORE R.N.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2012
Last Update Date: 01/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 LAKELAND DR
JACKSON MS
39216-4719
US

IV. Provider business mailing address

550 POST RD 709
RIDGELAND MS
39157-9601
US

V. Phone/Fax

Practice location:
  • Phone: 769-777-1058
  • Fax: 769-230-2864
Mailing address:
  • Phone: 601-513-1108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR882271
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: