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General NPI Number Information
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NPI Number | 1679991855
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Entity Type | Individual
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Provider Name | FRED MCMOORE
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Gender | Male
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Dates
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Enumeration Date | 04/03/2014
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Last Update Date | 04/03/2014
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Provider Practice Location Address
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Address Line | 13781 CHAGALL CT
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City | MORENO VALLEY
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State | CA
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Zip | 92553-6607
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Country | US
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Telephone | 951-255-5347
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Fax |
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Provider Business Mailing Address
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Address Line | 1161 HIDDEN VALLEY PKWY STE 114
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City | NORCO
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State | CA
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Zip | 92860-3917
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Country | US
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Telephone | 951-817-0230
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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 | 174400000X
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Taxonomy Name | Specialist
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License Number | 36518
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License Number State | CA
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