=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639204233
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOORE HOME
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 232 NEWPORT DR
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28540-4005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-353-9328
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 232 NEWPORT DR PO BOX 12541
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28540-4005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-353-9328
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. RICK A MOORE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 910-353-9328
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320600000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number | MHL-147
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------