Provider Demographics
NPI:1265572085
Name:MOORE, CARI LYNN (OD)
Entity type:Individual
Prefix:DR
First Name:CARI
Middle Name:LYNN
Last Name:MOORE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:CARI
Other - Middle Name:LYNN
Other - Last Name:LONDAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:217 E LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:WATSONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95076-4716
Mailing Address - Country:US
Mailing Address - Phone:831-724-3823
Mailing Address - Fax:831-724-2605
Practice Address - Street 1:3521 RICHLAND AVE
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-6311
Practice Address - Country:US
Practice Address - Phone:803-641-4646
Practice Address - Fax:803-641-4648
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10138T152W00000X
GAOPT003292152W00000X
SC2202152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5679634Medicaid
CABO427AOtherPTAN
SC2202OtherSC STATE LICENSE
CA5679634Medicaid
CABO427AMedicare PIN