Provider Demographics
NPI:1215029616
Name:SALLY W. MOORE, O.D., P.C.
Entity Type:Organization
Organization Name:SALLY W. MOORE, O.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:WONG
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:251-753-2978
Mailing Address - Street 1:8223 PINE LOG CT
Mailing Address - Street 2:
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-6152
Mailing Address - Country:US
Mailing Address - Phone:251-753-2978
Mailing Address - Fax:
Practice Address - Street 1:27520 US HIGHWAY 98
Practice Address - Street 2:
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-4812
Practice Address - Country:US
Practice Address - Phone:251-626-8950
Practice Address - Fax:251-626-5896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALSA38TA597152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALU91652Medicare UPIN