Provider Demographics
NPI:1255733986
Name:BRENDA K MOORE DO PA
Entity type:Organization
Organization Name:BRENDA K MOORE DO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:832-686-1965
Mailing Address - Street 1:1003 COLLEGE BLVD W
Mailing Address - Street 2:SUITE #2
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-1068
Mailing Address - Country:US
Mailing Address - Phone:850-678-0443
Mailing Address - Fax:
Practice Address - Street 1:1003 COLLEGE BLVD W
Practice Address - Street 2:SUITE #2
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-1068
Practice Address - Country:US
Practice Address - Phone:850-678-0443
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-25
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 12957261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center