Provider Demographics
NPI:1326609520
Name:MOORE, SUSIE (PERSONAL CARE AGENCY)
Entity Type:Individual
Prefix:
First Name:SUSIE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:PERSONAL CARE AGENCY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9330 W LINCOLN AVE STE 20
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-2300
Mailing Address - Country:US
Mailing Address - Phone:414-732-9469
Mailing Address - Fax:414-539-6645
Practice Address - Street 1:9330 W LINCOLN AVE STE 20
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2300
Practice Address - Country:US
Practice Address - Phone:414-732-9469
Practice Address - Fax:414-539-6645
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-27
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health