Provider Demographics
NPI:1942675244
Name:MOORE, SHAWN
Entity Type:Individual
Prefix:
First Name:SHAWN
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 1:1410 WASHINGTON BLVD
Mailing Address - Street 2:APT 1706
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48226-1719
Mailing Address - Country:US
Mailing Address - Phone:313-646-5591
Mailing Address - Fax:
Practice Address - Street 1:1410 WASHINGTON BLVD
Practice Address - Street 2:APT 1706
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48226-1719
Practice Address - Country:US
Practice Address - Phone:313-646-5591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-11
Last Update Date:2015-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM600765081141Medicaid