Provider Demographics
NPI:1659551935
Name:CHARLES A MOORE
Entity Type:Organization
Organization Name:CHARLES A MOORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:A
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-248-7630
Mailing Address - Street 1:PO BOX 309
Mailing Address - Street 2:
Mailing Address - City:MIDDLESBORO
Mailing Address - State:KY
Mailing Address - Zip Code:40965-0309
Mailing Address - Country:US
Mailing Address - Phone:606-248-7630
Mailing Address - Fax:606-248-8803
Practice Address - Street 1:123 N 19TH ST
Practice Address - Street 2:SUITE 201
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965-2865
Practice Address - Country:US
Practice Address - Phone:606-248-7630
Practice Address - Fax:606-248-8803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7975Medicare PIN