Provider Demographics
NPI:1467439299
Name:MOORE HEALTH SERVICES CORPORATION
Entity Type:Organization
Organization Name:MOORE HEALTH SERVICES CORPORATION
Other - Org Name:GEORGIA MANOR NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:LNFA
Authorized Official - Phone:806-259-3566
Mailing Address - Street 1:2611 W 46TH AVE
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79110-1735
Mailing Address - Country:US
Mailing Address - Phone:803-355-6517
Mailing Address - Fax:806-355-4190
Practice Address - Street 1:2611 W 46TH AVE
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79110-1735
Practice Address - Country:US
Practice Address - Phone:803-355-6517
Practice Address - Fax:806-355-4190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-22
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111093314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX000460406Medicaid
TX675851Medicare ID - Type Unspecified