Provider Demographics
NPI:1477160810
Name:MOORE, BRIAN CHADWICK
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:CHADWICK
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1227 BLUE SLIDE RD
Mailing Address - Street 2:
Mailing Address - City:THOMPSON FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59873-9470
Mailing Address - Country:US
Mailing Address - Phone:805-458-2326
Mailing Address - Fax:
Practice Address - Street 1:1227 BLUE SLIDE RD
Practice Address - Street 2:
Practice Address - City:THOMPSON FALLS
Practice Address - State:MT
Practice Address - Zip Code:59873-9470
Practice Address - Country:US
Practice Address - Phone:805-458-2326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider