Provider Demographics
NPI:1588805352
Name:MOORE, BRUNETTE
Entity Type:Individual
Prefix:MS
First Name:BRUNETTE
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 1:6503 MARSOL RD
Mailing Address - Street 2:SUITE 306
Mailing Address - City:MAYFIELD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44124-3568
Mailing Address - Country:US
Mailing Address - Phone:216-513-3801
Mailing Address - Fax:440-720-0771
Practice Address - Street 1:6503 MARSOL RD
Practice Address - Street 2:SUITE 306
Practice Address - City:MAYFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44124-3568
Practice Address - Country:US
Practice Address - Phone:216-513-3801
Practice Address - Fax:440-720-0771
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-09
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver