Healthcare Provider Details

I. General information

NPI: 1225963424
Provider Name (Legal Business Name): ZACHARY JEROME MOORE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2026
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1492 RYMCO DR
WINSTON SALEM NC
27103-2944
US

IV. Provider business mailing address

2203 SILAS CREEK PKWY APT B
WINSTON SALEM NC
27103-5028
US

V. Phone/Fax

Practice location:
  • Phone: 336-594-2802
  • Fax:
Mailing address:
  • Phone: 336-577-4905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberBACB-1395421
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: