MEDICARE: MS. BRUNETTE 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	172A00000X	Driver

General Provider Information

NPI Number	:	1588805352
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. BRUNETTE MOORE

Provider Business Mailing Address
First Line	:	6503 MARSOL RD
Second Line	:	SUITE 306
City	:	MAYFIELD HEIGHTS
State	:	OH
Zip	:	44124-3568
Country	:	US
Telephone Number	:	216-513-3801
Fax Number	:	440-720-0771

Provider Business Practice Location Address
First Line	:	6503 MARSOL RD
Second Line	:	SUITE 306
City	:	MAYFIELD HEIGHTS
State	:	OH
Zip	:	44124-3568
Country	:	US
Telephone Number	:	216-513-3801
Fax Number	:	440-720-0771

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

Provider Enumeration Date	:	03/09/2009
Last Update Date	:	03/09/2009

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