Provider Demographics
NPI:1275850646
Name:MOORE, LAURA C (RD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:C
Last Name:MOORE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8792
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-8792
Mailing Address - Country:US
Mailing Address - Phone:216-383-7813
Mailing Address - Fax:216-383-5350
Practice Address - Street 1:18599 LAKE SHORE BLVD
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44119-1093
Practice Address - Country:US
Practice Address - Phone:216-383-7813
Practice Address - Fax:216-383-5350
Is Sole Proprietor?:No
Enumeration Date:2010-04-26
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD5905133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered