Provider Demographics
NPI:1689029506
Name:MOORE, TIMOTHY
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:
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 66558
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70896-6558
Mailing Address - Country:US
Mailing Address - Phone:225-922-2700
Mailing Address - Fax:225-362-5319
Practice Address - Street 1:2455 WOODDALE BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70805-7569
Practice Address - Country:US
Practice Address - Phone:225-922-3169
Practice Address - Fax:225-922-3225
Is Sole Proprietor?:No
Enumeration Date:2016-04-28
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1548839Medicaid