=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720931439
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLEARWATER HEALTH DPC, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2026
-----------------------------------------------------
Last Update Date | 02/20/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1440 CHAPEL RIDGE RD STE 110
-----------------------------------------------------
City | APEX
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27502-8633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-586-1960
-----------------------------------------------------
Fax | 910-226-0957
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 322 SHADY LN
-----------------------------------------------------
City | CAMERON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28326-7440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-672-3225
-----------------------------------------------------
Fax | 910-226-0957
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | TANNER MOORE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 304-672-3225
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QD0401X
-----------------------------------------------------
Taxonomy Name | Diabetology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------