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General NPI Number Information
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NPI Number | 1104130780
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Entity Type | Organization
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Legal Business Name | MOORE TRANSPORT OF OFALLON LLC
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Dates
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Enumeration Date | 08/05/2010
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Last Update Date | 02/20/2013
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Provider Practice Location Address
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Address Line | 7597 PIERSIDE DR
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City | O FALLON
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State | MO
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Zip | 63368-7028
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Country | US
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Telephone | 636-633-2888
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Fax | 636-294-5435
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Provider Business Mailing Address
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Address Line | 7597 PIERSIDE DR
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City | O FALLON
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State | MO
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Zip | 63368-7028
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Country | US
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Telephone | 636-633-2888
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Fax | 636-294-5435
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Authorized Official
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Title or Position | OWNER
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Name | MRS. DEJA ENJOLI MOORE
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Credential | BA
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Telephone | 636-757-3021
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 343900000X
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Taxonomy Name | Non-emergency Medical Transport (VAN)
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License Number | PO52355003
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License Number State | MO
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