Provider Demographics
NPI:1649647066
Name:MOORE, TAUSHIMA (HAIR LOSS SPECIALIST)
Entity type:Individual
Prefix:
First Name:TAUSHIMA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:HAIR LOSS SPECIALIST
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 13
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTON
Mailing Address - State:NC
Mailing Address - Zip Code:27892-0013
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:122 HARRISON ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSTON
Practice Address - State:NC
Practice Address - Zip Code:27892-2464
Practice Address - Country:US
Practice Address - Phone:252-508-6691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-02
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC999711744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management