Provider Demographics
NPI:1578090981
Name:TIFFANY MOORE, O.D. INC, A PROFESSIONAL OPTOMETRIC CORPORATION
Entity Type:Organization
Organization Name:TIFFANY MOORE, O.D. INC, A PROFESSIONAL OPTOMETRIC CORPORATION
Other - Org Name:EMPIRE OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:707-542-1554
Mailing Address - Street 1:800 4TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-4505
Mailing Address - Country:US
Mailing Address - Phone:707-542-1554
Mailing Address - Fax:707-542-1252
Practice Address - Street 1:800 4TH ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4505
Practice Address - Country:US
Practice Address - Phone:707-542-1554
Practice Address - Fax:707-542-1252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-16
Last Update Date:2017-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15230152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty