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General NPI Number Information
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NPI Number | 1578090981
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Entity Type | Organization
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Legal Business Name | TIFFANY MOORE, O.D. INC, A PROFESSIONAL OPTOMETRIC CORPORATION
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Dates
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Enumeration Date | 05/16/2017
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Last Update Date | 08/29/2017
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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 | 707-542-1252
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Provider Business Mailing 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 | 707-542-1252
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Authorized Official
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Title or Position | OWNER
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Name | DR. TIFFANY MOORE
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Credential | OD
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Telephone | 707-542-1554
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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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