Healthcare Provider Details

I. General information

NPI: 1417885302
Provider Name (Legal Business Name): ELIJAH MOORE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 RED BANK RD
CINCINNATI OH
45227-3416
US

IV. Provider business mailing address

4000 RED BANK RD
CINCINNATI OH
45227-3416
US

V. Phone/Fax

Practice location:
  • Phone: 513-351-9768
  • Fax: 513-351-9809
Mailing address:
  • Phone: 513-351-9768
  • Fax: 513-351-9809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberOP.017992-S
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: