Provider Demographics
NPI:1679658686
Name:MOORE, ERICA (RD)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:853 N CHURCH ST
Practice Address - Street 2:SUITE 720
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3098
Practice Address - Country:US
Practice Address - Phone:864-560-6419
Practice Address - Fax:864-560-7498
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2017-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC866758133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDT1017Medicaid
SCP00662543OtherRAILROAD MEDICARE
SCQ340476067OtherMEDICARE PIN
SCQ340475019OtherMEDICARE PIN
SCQ340473365OtherMEDICARE PIN
SCQ340475193OtherMEDICARE PIN
SCQ340476066OtherMEDICARE PIN
SCQ34047Medicare PIN
SCQ340475019OtherMEDICARE PIN
SCQ340473365OtherMEDICARE PIN
SCQ34047Medicare UPIN
SCQ340475193Medicare PIN