MEDICARE: TIFFANY MOORE, O.D. INC, A PROFESSIONAL OPTOMETRIC CORPORATION

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	152W00000X	Optometrist	15230	CA

General Provider Information

NPI Number	:	1578090981
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIFFANY MOORE, O.D. INC, A PROFESSIONAL OPTOMETRIC CORPORATION

Provider Business Mailing Address
First Line	:	800 4TH ST
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95404-4505
Country	:	US
Telephone Number	:	707-542-1554
Fax Number	:	707-542-1252

Provider Business Practice Location Address
First Line	:	800 4TH ST
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95404-4505
Country	:	US
Telephone Number	:	707-542-1554
Fax Number	:	707-542-1252

Authorized Official
Title or Position	:	OWNER
Name	:	DR. TIFFANY MOORE
Credential	:	OD
Telephone Number	:	707-542-1554

Provider Enumeration Date	:	05/16/2017
Last Update Date	:	08/29/2017

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