Healthcare Provider Details

I. General information

NPI: 1770937732
Provider Name (Legal Business Name): PICKENS MOORE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2016
Last Update Date: 04/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E AZTEC AVE
GALLUP NM
87301-6256
US

IV. Provider business mailing address

3306 CHURCH ROCK ST
GALLUP NM
87301-4506
US

V. Phone/Fax

Practice location:
  • Phone: 505-863-7472
  • Fax: 505-863-7472
Mailing address:
  • Phone: 505-863-7472
  • Fax: 505-863-7472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberI-3118
License Number StateNM

VIII. Authorized Official

Name: MR. PICKENS MOORE
Title or Position: LISW
Credential:
Phone: 505-863-7472