Provider Demographics
NPI:1669667390
Name:MOORE AND HEALEY, PA
Entity Type:Organization
Organization Name:MOORE AND HEALEY, PA
Other - Org Name:MOORE AND HEALEY, PA
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:R
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-399-0667
Mailing Address - Street 1:4910 BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-4817
Mailing Address - Country:US
Mailing Address - Phone:904-399-0667
Mailing Address - Fax:904-399-3330
Practice Address - Street 1:4910 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-4817
Practice Address - Country:US
Practice Address - Phone:904-399-0667
Practice Address - Fax:904-399-3330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0027744174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK1172Medicare PIN
FL1669667390Medicare PIN