MEDICARE: GAMBRELL 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
1	374U00000X	Home Health Aide	800753572	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184200255
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GAMBRELL MOORE

Provider Business Mailing Address
First Line	:	4271 CYPRESS DR # 42
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39212-3406
Country	:	US
Telephone Number	:	601-983-6016
Fax Number	:

Provider Business Practice Location Address
First Line	:	4271 CYPRESS DR # 42
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39212-3406
Country	:	US
Telephone Number	:	601-983-6016
Fax Number	:

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

Provider Enumeration Date	:	03/19/2021
Last Update Date	:	03/19/2021

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Directions to “ GAMBRELL MOORE ” Practice Location

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