Provider Demographics
NPI:1699404764
Name:MOORE, VERONICA ELAINE
Entity Type:Individual
Prefix:
First Name:VERONICA
Middle Name:ELAINE
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:570 DICKSON RD
Mailing Address - Street 2:
Mailing Address - City:RIEGELWOOD
Mailing Address - State:NC
Mailing Address - Zip Code:28456-8067
Mailing Address - Country:US
Mailing Address - Phone:678-517-2786
Mailing Address - Fax:678-826-0581
Practice Address - Street 1:570 DICKSON RD
Practice Address - Street 2:
Practice Address - City:RIEGELWOOD
Practice Address - State:NC
Practice Address - Zip Code:28456-8067
Practice Address - Country:US
Practice Address - Phone:678-517-2786
Practice Address - Fax:678-826-0581
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-06
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver