Provider Demographics
NPI:1992860902
Name:MOORE, LORRAINE BENSON (MED)
Entity Type:Individual
Prefix:MS
First Name:LORRAINE
Middle Name:BENSON
Last Name:MOORE
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4981 WATERFORD DR SW
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-1736
Mailing Address - Country:US
Mailing Address - Phone:770-819-9314
Mailing Address - Fax:770-819-9314
Practice Address - Street 1:4981 WATERFORD DR SW
Practice Address - Street 2:
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126-1736
Practice Address - Country:US
Practice Address - Phone:770-819-9314
Practice Address - Fax:770-819-9314
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00862386AMedicaid