Provider Demographics
NPI:1508184714
Name:MOORE, HEATHER (LAC)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 SCENIC RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:CA
Mailing Address - Zip Code:94930-1523
Mailing Address - Country:US
Mailing Address - Phone:510-282-8466
Mailing Address - Fax:
Practice Address - Street 1:29 BOLINAS RD
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:CA
Practice Address - Zip Code:94930-1662
Practice Address - Country:US
Practice Address - Phone:510-282-8466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-12
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7369171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist