Provider Demographics
NPI:1558435263
Name:KERRY F. MOORE M.D.
Entity Type:Organization
Organization Name:KERRY F. MOORE M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:F
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-242-4101
Mailing Address - Street 1:16049 TUSCOLA RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-1319
Mailing Address - Country:US
Mailing Address - Phone:760-242-4101
Mailing Address - Fax:760-242-8256
Practice Address - Street 1:16049 TUSCOLA RD
Practice Address - Street 2:SUITE B
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-1319
Practice Address - Country:US
Practice Address - Phone:760-242-4101
Practice Address - Fax:760-242-8256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41582261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A415820Medicaid
CA00A415820Medicaid
CA00A415820Medicare ID - Type Unspecified