Provider Demographics
NPI:1376785824
Name:MOORE, PHILLIP TITUS (LPN)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:TITUS
Last Name:MOORE
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14401 IDAROSE AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44110-3648
Mailing Address - Country:US
Mailing Address - Phone:216-965-9273
Mailing Address - Fax:
Practice Address - Street 1:14401 IDAROSE AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44110-3648
Practice Address - Country:US
Practice Address - Phone:216-965-9273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-30
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH122898164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse