Provider Demographics
NPI:1306227749
Name:MOORE, JANICE
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 W BEACON RD APT 6
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-2862
Mailing Address - Country:US
Mailing Address - Phone:863-680-2966
Mailing Address - Fax:
Practice Address - Street 1:830 W BEACON RD APT 6
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-2862
Practice Address - Country:US
Practice Address - Phone:863-680-2966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-11
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No335E00000XSuppliersProsthetic/Orthotic Supplier