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General NPI Number Information
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NPI Number | 1699932012
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Entity Type | Individual
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Provider Name | SALLY WONG MOORE O.D.
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Gender | Female
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Dates
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Enumeration Date | 05/22/2008
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Last Update Date | 05/22/2008
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Provider Practice Location Address
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Address Line | 10040 COUNTY ROAD 48
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City | FAIRHOPE
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State | AL
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Zip | 36533
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Country | US
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Telephone | 251-990-9094
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Fax |
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Provider Business Mailing Address
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Address Line | 8223 PINE LOG CT
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City | DAPHNE
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State | AL
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Zip | 36526-6152
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Country | US
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Telephone | 251-753-2978
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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 | SA38TA597
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License Number State | AL
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