MEDICARE: MR. PHILLIP TITUS MOORE LPN

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	164W00000X	Licensed Practical Nurse	122898	OH

General Provider Information

NPI Number	:	1376785824
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PHILLIP TITUS MOORE LPN

Provider Business Mailing Address
First Line	:	14401 IDAROSE AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44110-3648
Country	:	US
Telephone Number	:	216-965-9273
Fax Number	:

Provider Business Practice Location Address
First Line	:	14401 IDAROSE AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44110-3648
Country	:	US
Telephone Number	:	216-965-9273
Fax Number	:

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

Provider Enumeration Date	:	03/30/2009
Last Update Date	:	03/30/2009

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