Provider Demographics
NPI:1134744790
Name:MOORE, CAMERON
Entity type:Individual
Prefix:
First Name:CAMERON
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 1:231 S 2ND E
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-2202
Mailing Address - Country:US
Mailing Address - Phone:208-534-8623
Mailing Address - Fax:
Practice Address - Street 1:231 S 2ND E
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2202
Practice Address - Country:US
Practice Address - Phone:208-534-8623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-10
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician