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General NPI Number Information
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NPI Number | 1679173967
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Entity Type | Individual
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Provider Name | TINA MARIE MOORE
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Gender | Female
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Dates
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Enumeration Date | 10/27/2020
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Last Update Date | 10/27/2020
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Provider Practice Location Address
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Address Line | 347 COVINGTON DR STE A
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City | WATERLOO
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State | IL
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Zip | 62298-3287
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Country | US
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Telephone | 618-257-2200
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Fax | 618-257-2205
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Provider Business Mailing Address
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Address Line | 347 COVINGTON DR STE A
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City | WATERLOO
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State | IL
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Zip | 62298-3287
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Country | US
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Telephone | 618-257-2200
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Fax | 618-257-2205
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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 | 374U00000X
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Taxonomy Name | Home Health Aide
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License Number | 3000256
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 372600000X
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Taxonomy Name | Adult Companion
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License Number | 3000256
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 376J00000X
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Taxonomy Name | Homemaker
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License Number | 3000256
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License Number State | IL
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