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General NPI Number Information
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NPI Number | 1770937732
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Entity Type | Organization
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Legal Business Name | PICKENS MOORE
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Dates
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Enumeration Date | 04/15/2016
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Last Update Date | 04/15/2016
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Provider Practice Location Address
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Address Line | 100 E AZTEC AVE
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City | GALLUP
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State | NM
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Zip | 87301-6256
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Country | US
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Telephone | 505-863-7472
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Fax | 505-863-7472
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Provider Business Mailing Address
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Address Line | 3306 CHURCH ROCK ST
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City | GALLUP
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State | NM
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Zip | 87301-4506
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Country | US
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Telephone | 505-863-7472
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Fax | 505-863-7472
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Authorized Official
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Title or Position | LISW
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Name | MR. PICKENS MOORE
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Credential |
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Telephone | 505-863-7472
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | I-3118
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License Number State | NM
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