Healthcare Provider Details

I. General information

NPI: 1316783574
Provider Name (Legal Business Name): JUSTIN TYLER MOORE NRP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2024
Last Update Date: 07/06/2024
Certification Date: 07/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 E TRADE ST STE B100
FOREST CITY NC
28043-2201
US

IV. Provider business mailing address

PO BOX 335
FOREST CITY NC
28043-0335
US

V. Phone/Fax

Practice location:
  • Phone: 828-220-4174
  • Fax:
Mailing address:
  • Phone: 828-220-4174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146L00000X
TaxonomyParamedic
License NumberP016291
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: