Provider Demographics
NPI:1205272564
Name:MOORE, LAUREN LEE (CD)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:LEE
Last Name:MOORE
Suffix:
Gender:F
Credentials:CD
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:LEE
Other - Last Name:SHEPARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CD
Mailing Address - Street 1:1905 E HUEBBE PKWY
Mailing Address - Street 2:BELOIT HEALTH SYSTEM INC
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-1842
Mailing Address - Country:US
Mailing Address - Phone:608-364-2200
Mailing Address - Fax:608-363-7395
Practice Address - Street 1:1905 E HUEBBE PKWY
Practice Address - Street 2:1905 E. HUEBBE PARKWAY
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-1842
Practice Address - Country:US
Practice Address - Phone:608-364-2200
Practice Address - Fax:608-363-7395
Is Sole Proprietor?:No
Enumeration Date:2013-05-14
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2162-29133V00000X
IL164-005483133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered