Provider Demographics
NPI:1053851147
Name:MOORE, SHATORIA
Entity Type:Individual
Prefix:
First Name:SHATORIA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3625 YOUREE DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-2121
Mailing Address - Country:US
Mailing Address - Phone:318-742-3408
Mailing Address - Fax:
Practice Address - Street 1:305 HOMER RD
Practice Address - Street 2:
Practice Address - City:MINDEN
Practice Address - State:LA
Practice Address - Zip Code:71055
Practice Address - Country:US
Practice Address - Phone:318-639-9562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA7770001358535202Medicaid