Healthcare Provider Details

I. General information

NPI: 1639204233
Provider Name (Legal Business Name): MOORE HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

232 NEWPORT DR
JACKSONVILLE NC
28540-4005
US

IV. Provider business mailing address

232 NEWPORT DR PO BOX 12541
JACKSONVILLE NC
28540-4005
US

V. Phone/Fax

Practice location:
  • Phone: 910-353-9328
  • Fax:
Mailing address:
  • Phone: 910-353-9328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberMHL-147
License Number StateNC

VIII. Authorized Official

Name: MR. RICK A MOORE
Title or Position: ADMINISTRATOR
Credential:
Phone: 910-353-9328