Provider Demographics
NPI:1104384262
Name:MOORE, TAVARIUS JERRELL
Entity type:Individual
Prefix:
First Name:TAVARIUS
Middle Name:JERRELL
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 1:206 FRIENDLY RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27217-2502
Mailing Address - Country:US
Mailing Address - Phone:804-624-3515
Mailing Address - Fax:
Practice Address - Street 1:206 FRIENDLY RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27217-2502
Practice Address - Country:US
Practice Address - Phone:804-624-3515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-07
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL-001-107311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home