MEDICARE: MRS. JUDITH GOTHARD 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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1417398652
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JUDITH GOTHARD MOORE

Provider Business Mailing Address
First Line	:	1413 INDIAN WOODS DR
Second Line	:
City	:	GREENSBORO
State	:	GA
Zip	:	30642-2007
Country	:	US
Telephone Number	:	706-347-0655
Fax Number	:

Provider Business Practice Location Address
First Line	:	1413 INDIAN WOODS DR
Second Line	:
City	:	GREENSBORO
State	:	GA
Zip	:	30642-2007
Country	:	US
Telephone Number	:	706-347-0655
Fax Number	:	706-453-0019

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

Provider Enumeration Date	:	07/16/2013
Last Update Date	:	07/16/2013

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