Provider Demographics
NPI:1568167823
Name:MOORE, CANDICE
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10957 CORNERSTONE PL
Mailing Address - Street 2:
Mailing Address - City:KEITHVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71047-8587
Mailing Address - Country:US
Mailing Address - Phone:318-680-7697
Mailing Address - Fax:
Practice Address - Street 1:101 N FRONT ST
Practice Address - Street 2:
Practice Address - City:OAK GROVE
Practice Address - State:LA
Practice Address - Zip Code:71263-7641
Practice Address - Country:US
Practice Address - Phone:318-680-7697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-04
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)