Provider Demographics
NPI:1497327613
Name:MOORE BOUTIQUE, LLC
Entity Type:Organization
Organization Name:MOORE BOUTIQUE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:ALTHEA
Authorized Official - Middle Name:MOORE
Authorized Official - Last Name:LACHICOTTE
Authorized Official - Suffix:
Authorized Official - Credentials:RN; JD
Authorized Official - Phone:904-246-7267
Mailing Address - Street 1:PO BOX 26087
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32226-6087
Mailing Address - Country:US
Mailing Address - Phone:904-334-1293
Mailing Address - Fax:904-757-6528
Practice Address - Street 1:1825 3RD ST N STE B
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-4840
Practice Address - Country:US
Practice Address - Phone:904-372-4534
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-15
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care