Healthcare Provider Details

I. General information

NPI: 1861051518
Provider Name (Legal Business Name): BRENDEN MOORE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2019
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3735 GLENLAKE DR STE 250
CHARLOTTE NC
28208-6866
US

IV. Provider business mailing address

3735 GLENLAKE DR STE 250
CHARLOTTE NC
28208-6866
US

V. Phone/Fax

Practice location:
  • Phone: 704-749-5800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number82249
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: