Healthcare Provider Details

I. General information

NPI: 1275602443
Provider Name (Legal Business Name): ELIZABETH O MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 08/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5005 N PIEDRAS ST
EL PASO TX
79920-5001
US

IV. Provider business mailing address

4300 LOMA CLARA CT
EL PASO TX
79934-3806
US

V. Phone/Fax

Practice location:
  • Phone: 915-742-9722
  • Fax:
Mailing address:
  • Phone: 915-822-2520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License Number141774
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: