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General NPI Number Information
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NPI Number | 1205137304
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Entity Type | Organization
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Legal Business Name | MOORE HEALTHY FAMILY MEDICAL CLINIC, LLC
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Dates
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Enumeration Date | 11/06/2010
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Last Update Date | 04/18/2013
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Provider Practice Location Address
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Address Line | 5604 OLD CANTON RD
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City | JACKSON
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State | MS
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Zip | 39211-4217
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Country | US
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Telephone | 601-991-1044
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Fax | 601-991-9868
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Provider Business Mailing Address
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Address Line | 5604 OLD CANTON RD
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City | JACKSON
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State | MS
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Zip | 39211-4217
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Country | US
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Telephone | 601-991-1044
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Fax | 601-991-9868
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Authorized Official
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Title or Position | OWNER
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Name | DR. ROBERT L MOORE
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Credential | MD
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Telephone | 601-307-2450
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | MS18036
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License Number State | MS
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