Provider Demographics
NPI:1205140449
Name:MOORE, KIM
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 225
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95901-0005
Mailing Address - Country:US
Mailing Address - Phone:530-749-6413
Mailing Address - Fax:530-740-4928
Practice Address - Street 1:1114 YUBA ST
Practice Address - Street 2:#207
Practice Address - City:MARYSVILLE
Practice Address - State:CA
Practice Address - Zip Code:95901-4838
Practice Address - Country:US
Practice Address - Phone:530-749-6413
Practice Address - Fax:530-740-4928
Is Sole Proprietor?:No
Enumeration Date:2010-07-29
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator