Provider Demographics
NPI:1134321359
Name:MOORE, TIA M
Entity Type:Individual
Prefix:MS
First Name:TIA
Middle Name:M
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 1:6897 W M 21
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:MI
Mailing Address - Zip Code:48879-9509
Mailing Address - Country:US
Mailing Address - Phone:202-489-4842
Mailing Address - Fax:989-224-1925
Practice Address - Street 1:6897 W M 21
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:MI
Practice Address - Zip Code:48879-9509
Practice Address - Country:US
Practice Address - Phone:202-489-4842
Practice Address - Fax:989-224-1925
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
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