Provider Demographics
NPI:1164135158
Name:MOORE, TAVION (CMA)
Entity Type:Individual
Prefix:
First Name:TAVION
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:CMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13059 S EVANS AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60827-1305
Mailing Address - Country:US
Mailing Address - Phone:447-216-8803
Mailing Address - Fax:
Practice Address - Street 1:723 OAK ST APT 206
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-3969
Practice Address - Country:US
Practice Address - Phone:447-216-8803
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-04
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health