Provider Demographics
NPI:1043597768
Name:MOORE, BRENDAN MICHAEL
Entity Type:Individual
Prefix:
First Name:BRENDAN
Middle Name:MICHAEL
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2D MARINE SPECIAL OPERATIONS BATTALION
Mailing Address - Street 2:PCS BOX 20183
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28542-0183
Mailing Address - Country:US
Mailing Address - Phone:910-440-7704
Mailing Address - Fax:
Practice Address - Street 1:2D MARINE SPECIAL OPERATIONS BATTALION
Practice Address - Street 2:PCS BOX 20183
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28542-0183
Practice Address - Country:US
Practice Address - Phone:910-440-7704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-09
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC393524351710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman