=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972399624
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ETHAN RICHARD MOORE RN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2025
-----------------------------------------------------
Last Update Date | 06/03/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3700 KOLBE RD
-----------------------------------------------------
City | LORAIN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44053-1611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-960-3054
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20800 HAWLEY RD
-----------------------------------------------------
City | WELLINGTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44090-9411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-865-5248
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163WC0200X
-----------------------------------------------------
Taxonomy Name | Critical Care Medicine Registered Nurse
-----------------------------------------------------
License Number | RN.494812
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------