MEDICARE: WILLIE JUNIOR MOYER III

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	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1730531096
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILLIE JUNIOR MOYER III

Provider Business Mailing Address
First Line	:	3055 E ESCOBA DR
Second Line	:
City	:	PALM SPRINGS
State	:	CA
Zip	:	92264-5522
Country	:	US
Telephone Number	:	336-423-2576
Fax Number	:

Provider Business Practice Location Address
First Line	:	3055 E ESCOBA DR
Second Line	:
City	:	PALM SPRINGS
State	:	CA
Zip	:	92264-5522
Country	:	US
Telephone Number	:	336-423-2576
Fax Number	:

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

Provider Enumeration Date	:	07/11/2016
Last Update Date	:	07/11/2016

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