Provider Demographics
NPI:1619518214
Name:MOORE, PHILLIP DANIEL
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:DANIEL
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 E DENMAN AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75901-5817
Mailing Address - Country:US
Mailing Address - Phone:936-994-7010
Mailing Address - Fax:
Practice Address - Street 1:1520 E DENMAN AVE STE 102
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75901-5817
Practice Address - Country:US
Practice Address - Phone:936-994-7010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-04
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0000000000OtherOBTAINING