MEDICARE: FRED MCMOORE

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	174400000X	Specialist	36518	CA

General Provider Information

NPI Number	:	1679991855
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FRED MCMOORE

Provider Business Mailing Address
First Line	:	1161 HIDDEN VALLEY PKWY STE 114
Second Line	:
City	:	NORCO
State	:	CA
Zip	:	92860-3917
Country	:	US
Telephone Number	:	951-817-0230
Fax Number	:

Provider Business Practice Location Address
First Line	:	13781 CHAGALL CT
Second Line	:
City	:	MORENO VALLEY
State	:	CA
Zip	:	92553-6607
Country	:	US
Telephone Number	:	951-255-5347
Fax Number	:

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

Provider Enumeration Date	:	04/03/2014
Last Update Date	:	04/03/2014

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Directions to “ FRED MCMOORE ” Practice Location

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