Provider Demographics
NPI:1801364310
Name:MOORE, SAM L III (M ED)
Entity Type:Individual
Prefix:MR
First Name:SAM
Middle Name:L
Last Name:MOORE
Suffix:III
Gender:M
Credentials:M ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 OAK CIR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-2722
Mailing Address - Country:US
Mailing Address - Phone:318-557-9254
Mailing Address - Fax:
Practice Address - Street 1:114 INEICHEN ST STE A
Practice Address - Street 2:
Practice Address - City:RAYVILLE
Practice Address - State:LA
Practice Address - Zip Code:71269-3223
Practice Address - Country:US
Practice Address - Phone:318-417-7780
Practice Address - Fax:318-728-1140
Is Sole Proprietor?:No
Enumeration Date:2018-11-02
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator