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NPI Code Detail

MEDICARE: KENDRICK LAMAR MOORE

MEDICARE: KENDRICK LAMAR MOORE
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
1172V00000XCommunity Health Worker

General Provider Information

NPI Number : 1104781962
Entity Type Code : Individual
Provider Name (Legal Business Name) : KENDRICK LAMAR MOORE
Provider Business Mailing Address
First Line : 6624 RUSTIC RIDGE TRL
Second Line :
City : GRAND BLANC
State : MI
Zip : 48439-4955
Country : US
Telephone Number : 833-478-9464
Fax Number : 810-462-1093
Provider Business Practice Location Address
First Line : 6624 RUSTIC RIDGE TRL
Second Line :
City : GRAND BLANC
State : MI
Zip : 48439-4955
Country : US
Telephone Number : 833-478-9464
Fax Number : 810-462-1093
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/23/2025
Last Update Date : 12/23/2025

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Directions to “ KENDRICK LAMAR MOORE ” Practice Location

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