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General NPI Number Information
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NPI Number | 1164135158
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Entity Type | Individual
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Provider Name | TAVION MOORE C.M.A
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Gender | Male
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Dates
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Enumeration Date | 01/04/2023
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Last Update Date | 01/04/2023
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Provider Practice Location Address
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Address Line | 723 OAK ST APT 206
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City | DANVILLE
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State | IL
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Zip | 61832-3969
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Country | US
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Telephone | 447-216-8803
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Fax |
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Provider Business Mailing Address
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Address Line | 13059 S EVANS AVE
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City | CHICAGO
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State | IL
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Zip | 60827-1305
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Country | US
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Telephone | 447-216-8803
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State |
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