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General NPI Number Information
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NPI Number | 1841679891
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Entity Type | Organization
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Legal Business Name | COREY A. MOORE UBU SPORTS MENTORING
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Dates
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Enumeration Date | 05/22/2015
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Last Update Date | 04/20/2016
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Provider Practice Location Address
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Address Line | 5135 CAMINO AL NORTE AVE., SUITE 100
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City | NORTH LAS VEGAS
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State | NV
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Zip | 89031-8104
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Country | US
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Telephone | 941-587-4953
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Fax | 702-853-7001
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Provider Business Mailing Address
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Address Line | 5135 CAMINO AL NORTE AVE., SUITE 100
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City | NORTH LAS VEGAS
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State | NV
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Zip | 89031-8104
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Country | US
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Telephone | 941-587-4953
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Fax | 702-853-7001
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Authorized Official
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Title or Position | OWNER/DIRECT SUPERVISON
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Name | MR. COREY A. MOORE
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Credential | BS, MBA
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Telephone | 941-587-4953
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | NV20151051263
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License Number State | NV
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