MEDICARE: MRS. SUZANNE F MOORE CALM

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	372600000X	Adult Companion

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	20553605	OTHER	TX	DRIVER LICENSE

General Provider Information

NPI Number	:	1710513239
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SUZANNE F MOORE CALM

Provider Business Mailing Address
First Line	:	2321 S BELT LINE RD STE 148
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75051-4182
Country	:	US
Telephone Number	:	214-396-5288
Fax Number	:	469-660-0065

Provider Business Practice Location Address
First Line	:	5801 RAYBURN DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76133-3026
Country	:	US
Telephone Number	:	682-707-2524
Fax Number	:	469-660-0065

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

Provider Enumeration Date	:	03/16/2020
Last Update Date	:	03/16/2020

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