MEDICARE: SANDRA J 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

General Provider Information

NPI Number	:	1215710843
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDRA J MOORE

Provider Business Mailing Address
First Line	:	14256 CLOVERLAWN ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48238-2430
Country	:	US
Telephone Number	:	313-407-2198
Fax Number	:

Provider Business Practice Location Address
First Line	:	25545 BRIAR DR
Second Line	:
City	:	OAK PARK
State	:	MI
Zip	:	48237-1335
Country	:	US
Telephone Number	:	313-407-2198
Fax Number	:

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

Provider Enumeration Date	:	08/16/2023
Last Update Date	:	08/16/2023

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Directions to “ SANDRA J MOORE ” Practice Location

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