Healthcare Provider Details

I. General information

NPI: 1205137304
Provider Name (Legal Business Name): MOORE HEALTHY FAMILY MEDICAL CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2010
Last Update Date: 04/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5604 OLD CANTON RD
JACKSON MS
39211-4217
US

IV. Provider business mailing address

5604 OLD CANTON RD
JACKSON MS
39211-4217
US

V. Phone/Fax

Practice location:
  • Phone: 601-991-1044
  • Fax: 601-991-9868
Mailing address:
  • Phone: 601-991-1044
  • Fax: 601-991-9868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberMS18036
License Number StateMS

VIII. Authorized Official

Name: DR. ROBERT L MOORE
Title or Position: OWNER
Credential: MD
Phone: 601-307-2450