MEDICARE: JODI LYNN MOORE RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WS0200X	School Registered Nurse	R046845	SD

General Provider Information

NPI Number	:	1033606900
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JODI LYNN MOORE RN

Provider Business Mailing Address
First Line	:	410 E MONROE ST
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57701-1424
Country	:	US
Telephone Number	:	605-341-6448
Fax Number	:	605-341-2941

Provider Business Practice Location Address
First Line	:	410 E MONROE ST
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57701-1424
Country	:	US
Telephone Number	:	605-341-6448
Fax Number	:	605-341-2941

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/17/2018
Last Update Date	:	04/17/2018

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