Provider Demographics
NPI:1275104655
Name:MOORE, RICHARD L
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:L
Last Name:MOORE
Suffix:
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 1:5000 GATEWAY DR
Mailing Address - Street 2:SUITE 213
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256
Mailing Address - Country:US
Mailing Address - Phone:330-461-1164
Mailing Address - Fax:
Practice Address - Street 1:5000 GATEWAY DR
Practice Address - Street 2:SUITE 213
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256
Practice Address - Country:US
Practice Address - Phone:330-461-1164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-07
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251X00000XAgenciesSupports Brokerage