Provider Demographics
NPI:1417840240
Name:MOORE, BRANDON LEE
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:LEE
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 1:7101 HIGHWAY 531
Mailing Address - Street 2:
Mailing Address - City:HEFLIN
Mailing Address - State:LA
Mailing Address - Zip Code:71039-3543
Mailing Address - Country:US
Mailing Address - Phone:318-550-6397
Mailing Address - Fax:
Practice Address - Street 1:1945 E 70TH ST STE E-2
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5347
Practice Address - Country:US
Practice Address - Phone:318-227-4999
Practice Address - Fax:318-300-1149
Is Sole Proprietor?:No
Enumeration Date:2025-05-30
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator