Provider Demographics
NPI:1528396314
Name:MOORE, JOEY W (LICENSED PRACTICAL N)
Entity Type:Individual
Prefix:
First Name:JOEY
Middle Name:W
Last Name:MOORE
Suffix:
Gender:M
Credentials:LICENSED PRACTICAL N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 ROBERTS DRIVE
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:AR
Mailing Address - Zip Code:71655
Mailing Address - Country:US
Mailing Address - Phone:870-367-9732
Mailing Address - Fax:870-460-6133
Practice Address - Street 1:1308 W 5TH STREET
Practice Address - Street 2:
Practice Address - City:CROSSETT
Practice Address - State:AR
Practice Address - Zip Code:71635
Practice Address - Country:US
Practice Address - Phone:870-364-6471
Practice Address - Fax:870-364-9753
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-07
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARL49184171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator