Provider Demographics
NPI:1811544869
Name:MOORE, BRYAN L
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:L
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 1:9247 PLUME GRASS ST
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92883-8166
Mailing Address - Country:US
Mailing Address - Phone:714-742-0914
Mailing Address - Fax:
Practice Address - Street 1:9247 PLUME GRASS ST
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92883-8166
Practice Address - Country:US
Practice Address - Phone:714-742-0914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-23
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician