Healthcare Provider Details

I. General information

NPI: 1073432712
Provider Name (Legal Business Name): JUSTIN MOORE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3710 UNIVERSITY DR
DURHAM NC
27707-6203
US

IV. Provider business mailing address

3 SUGAR CREEK CT
DURHAM NC
27713-7106
US

V. Phone/Fax

Practice location:
  • Phone: 984-276-4659
  • Fax:
Mailing address:
  • Phone: 423-782-8251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberA23043
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: