MEDICARE: CODI 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	103K00000X	Behavior Analyst		SC

General Provider Information

NPI Number	:	1194436840
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CODI MOORE

Provider Business Mailing Address
First Line	:	355 S MAIN ST
Second Line	:	1ST FLOOR
City	:	GREENVILLE
State	:	SC
Zip	:	29601-2923
Country	:	US
Telephone Number	:	855-832-6727
Fax Number	:

Provider Business Practice Location Address
First Line	:	355 S MAIN ST
Second Line	:	1ST FLOOR
City	:	GREENVILLE
State	:	SC
Zip	:	29601-2923
Country	:	US
Telephone Number	:	855-832-6727
Fax Number	:

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

Provider Enumeration Date	:	12/13/2022
Last Update Date	:	12/05/2025

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Directions to “ CODI MOORE ” Practice Location

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