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General NPI Number Information
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NPI Number | 1417200288
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Entity Type | Individual
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Provider Name | TIFFANY LOUISE MOORE O.D.
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Gender | Female
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Dates
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Enumeration Date | 10/18/2012
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Last Update Date | 06/10/2015
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Provider Practice Location Address
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Address Line | 800 4TH ST
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City | SANTA ROSA
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State | CA
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Zip | 95404-4505
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Country | US
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Telephone | 707-542-1554
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Fax |
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Provider Business Mailing Address
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Address Line | 2024 MONTECITO AVE
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City | SANTA ROSA
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State | CA
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Zip | 95404
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Country | UM
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Telephone |
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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 | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 15230
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License Number State | CA
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