Provider Demographics
NPI:1093453532
Name:MOORE, THOMAS PHILLIP II
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:PHILLIP
Last Name:MOORE
Suffix:II
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 1:58923 BUSINESS CENTER DR STE E
Mailing Address - Street 2:
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92284-7311
Mailing Address - Country:US
Mailing Address - Phone:760-365-7209
Mailing Address - Fax:
Practice Address - Street 1:58923 BUSINESS CENTER DR STE E
Practice Address - Street 2:
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284-7311
Practice Address - Country:US
Practice Address - Phone:760-365-7209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-24
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty