MEDICARE: MOORE BOUTIQUE, LLC

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	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1497327613
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOORE BOUTIQUE, LLC

Provider Business Mailing Address
First Line	:	PO BOX 26087
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32226-6087
Country	:	US
Telephone Number	:	904-334-1293
Fax Number	:	904-757-6528

Provider Business Practice Location Address
First Line	:	1825 3RD ST N STE B
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-4840
Country	:	US
Telephone Number	:	904-372-4534
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	MS. ALTHEA MOORE LACHICOTTE
Credential	:	RN; JD
Telephone Number	:	904-246-7267

Provider Enumeration Date	:	07/15/2021
Last Update Date	:	07/15/2021

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Directions to “MOORE BOUTIQUE, LLC ” Practice Location

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