Provider Demographics
NPI:1053631770
Name:MOORE FAMILY EYECARE, LLC
Entity Type:Organization
Organization Name:MOORE FAMILY EYECARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:LORAN
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:417-926-3937
Mailing Address - Street 1:1902 WEST 19TH STREET
Mailing Address - Street 2:STE. A
Mailing Address - City:MOUNTAIN GROVE
Mailing Address - State:MO
Mailing Address - Zip Code:65711-1221
Mailing Address - Country:US
Mailing Address - Phone:417-926-3937
Mailing Address - Fax:417-926-3952
Practice Address - Street 1:1902 WEST 19TH STREET
Practice Address - Street 2:STE. A
Practice Address - City:MOUNTAIN GROVE
Practice Address - State:MO
Practice Address - Zip Code:65711-1221
Practice Address - Country:US
Practice Address - Phone:417-926-3937
Practice Address - Fax:417-926-3952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-04
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT03463261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO317443505Medicaid
MO6794550001Medicare NSC