Provider Demographics
NPI:1659505683
Name:MOORE, STANLEY (BA)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1921 RANSOM PLACE
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013
Mailing Address - Country:US
Mailing Address - Phone:615-586-9155
Mailing Address - Fax:
Practice Address - Street 1:1921 RANSOM PLACE
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:TN
Practice Address - Zip Code:37013
Practice Address - Country:US
Practice Address - Phone:615-586-9155
Practice Address - Fax:615-586-9155
Is Sole Proprietor?:No
Enumeration Date:2009-05-05
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30604011Medicaid