Provider Demographics
NPI:1770928517
Name:MOORE, SPENCER KEITH (CW)
Entity type:Individual
Prefix:
First Name:SPENCER
Middle Name:KEITH
Last Name:MOORE
Suffix:
Gender:M
Credentials:CW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2035 SAINT JOHN AVE
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-2209
Mailing Address - Country:US
Mailing Address - Phone:731-541-8200
Mailing Address - Fax:731-660-8739
Practice Address - Street 1:1804 HIGHWAY 45 BYP
Practice Address - Street 2:SUITE 604
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-4436
Practice Address - Country:US
Practice Address - Phone:731-660-7971
Practice Address - Fax:731-660-8739
Is Sole Proprietor?:No
Enumeration Date:2013-05-07
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator