Healthcare Provider Details

I. General information

NPI: 1245998962
Provider Name (Legal Business Name): MANDY K MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2021
Last Update Date: 11/30/2021
Certification Date: 11/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14014 ROUTE 31
ALBION NY
14411-9301
US

IV. Provider business mailing address

11493 PLATTEN RD
LYNDONVILLE NY
14098-9608
US

V. Phone/Fax

Practice location:
  • Phone: 585-589-7066
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: