Provider Demographics
NPI:1629165097
Name:MOORE, JAMES KNOBLE JR (BA)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:KNOBLE
Last Name:MOORE
Suffix:JR
Gender:M
Credentials:BA
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Mailing Address - Street 1:1161 N EL DORADO PL STE 103
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85715-4607
Mailing Address - Country:US
Mailing Address - Phone:520-748-7108
Mailing Address - Fax:520-748-1458
Practice Address - Street 1:10247 E COVINGTON ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85748-2146
Practice Address - Country:US
Practice Address - Phone:520-290-9055
Practice Address - Fax:520-748-1458
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ4698385HR2055X, 253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ754871Medicaid