Healthcare Provider Details

I. General information

NPI: 1861937740
Provider Name (Legal Business Name): GLORIA C MOORE DEM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2016
Last Update Date: 12/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4618 S RUSSELL ST APT B
HOLLADAY UT
84117-4549
US

IV. Provider business mailing address

4618 S RUSSELL ST APT B
HOLLADAY UT
84117-4549
US

V. Phone/Fax

Practice location:
  • Phone: 214-717-0689
  • Fax:
Mailing address:
  • Phone: 214-717-0689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175M00000X
TaxonomyLay Midwife
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: