Provider Demographics
NPI:1467771360
Name:MOORE, LAUREN E
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:E
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:PO BOX 57752
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85732-7752
Mailing Address - Country:US
Mailing Address - Phone:520-360-9423
Mailing Address - Fax:877-727-4505
Practice Address - Street 1:2219 N RALPH AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-3262
Practice Address - Country:US
Practice Address - Phone:520-360-9423
Practice Address - Fax:877-727-4505
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-18
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3011610171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor