Healthcare Provider Details

I. General information

NPI: 1053117531
Provider Name (Legal Business Name): BOBBY MOORE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2025
Last Update Date: 02/24/2025
Certification Date: 02/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4837 MASON DIXON HIGHWAY
PENTRESS WV
26544
US

IV. Provider business mailing address

PO BOX 129
BLACKSVILLE WV
26521-0129
US

V. Phone/Fax

Practice location:
  • Phone: 304-290-7317
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: