Provider Demographics
NPI:1164773040
Name:MOORE, GERRY DELAYNE SR
Entity Type:Individual
Prefix:MR
First Name:GERRY
Middle Name:DELAYNE
Last Name:MOORE
Suffix:SR
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 1:85 RENDI LN
Mailing Address - Street 2:
Mailing Address - City:BAXLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31513-6816
Mailing Address - Country:US
Mailing Address - Phone:912-347-9043
Mailing Address - Fax:912-367-0986
Practice Address - Street 1:85 RENDI LN
Practice Address - Street 2:
Practice Address - City:BAXLEY
Practice Address - State:GA
Practice Address - Zip Code:31513-6816
Practice Address - Country:US
Practice Address - Phone:912-347-9043
Practice Address - Fax:912-367-0986
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-02
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver