Healthcare Provider Details

I. General information

NPI: 1528263514
Provider Name (Legal Business Name): CECILIA ANN MOORE RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2007
Last Update Date: 01/30/2025
Certification Date: 01/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 4TH ST STOP 9903
LUBBOCK TX
79430-9903
US

IV. Provider business mailing address

PO BOX 5865
LUBBOCK TX
79408-5865
US

V. Phone/Fax

Practice location:
  • Phone: 806-743-7337
  • Fax: 806-743-7329
Mailing address:
  • Phone: 806-743-2898
  • Fax: 806-743-2787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License NumberDT80334
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT80334
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: