Provider Demographics
NPI:1083394647
Name:MOORE, WILLIAM DYWAYNE (EMT)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:DYWAYNE
Last Name:MOORE
Suffix:
Gender:M
Credentials:EMT
Other - Prefix:
Other - First Name:DYWAYNE
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:EMT
Mailing Address - Street 1:955 COUNTY ROAD 255
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35740-7425
Mailing Address - Country:US
Mailing Address - Phone:256-695-7348
Mailing Address - Fax:256-437-6509
Practice Address - Street 1:205 KENTUCKY AVE SUITE 1
Practice Address - Street 2:STEVENSON, AL 35772
Practice Address - City:STEVENSON
Practice Address - State:AL
Practice Address - Zip Code:35772
Practice Address - Country:US
Practice Address - Phone:566-957-3482
Practice Address - Fax:256-437-6509
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-19
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment