Healthcare Provider Details

I. General information

NPI: 1558294082
Provider Name (Legal Business Name): FREDERICK MOORE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2026
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 4TH ST NW SUITE 102 #1821
ALBUQUERQUE NM
87102
US

IV. Provider business mailing address

500 4TH ST NW SUITE 102 #1821
ALBUQUERQUE NM
87102
US

V. Phone/Fax

Practice location:
  • Phone: 386-215-2886
  • Fax:
Mailing address:
  • Phone: 386-215-2886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: