Provider Demographics
NPI:1154052264
Name:MOORE, LOIS T
Entity Type:Individual
Prefix:
First Name:LOIS
Middle Name:T
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 1:100 WALTON AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40422-8414
Mailing Address - Country:US
Mailing Address - Phone:859-236-9866
Mailing Address - Fax:859-236-1649
Practice Address - Street 1:100 WALTON AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-8414
Practice Address - Country:US
Practice Address - Phone:859-236-9866
Practice Address - Fax:859-236-1649
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-20
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY111722156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician