=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164160032
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGELA W MOORE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2022
-----------------------------------------------------
Last Update Date | 05/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2411 S NC HIGHWAY 11
-----------------------------------------------------
City | ROSE HILL
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28458-8467
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-289-7678
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2750 WILLARD RD
-----------------------------------------------------
City | WILLARD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28478-6472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-289-7678
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------